СИНДРОМ ХРОНИЧЕСКОЙ БОЛИ-CHRONIC PAIN SYNDROME

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Polyunsaturated fatty acids are more unstable than monounsaturated and saturated fatty acids. This means that they become rancid (oxidized) more easily when exposed to oxygen, light and heat, and have the ability to form trans fatty acids. We are continually told by health authorities that polyunsaturated fats are healthy, and saturated fats are bad for us.

Vegetable oils that have become oxidized act as free radicals in the body. Free radicals can cause damage to our cells and DNA; they age us more quickly and have been linked to the development of heart disease and cancer. Importantly, new research has shown that cholesterol itself is not the problem, but oxidized cholesterol is a bigger risk factor for heart disease. The more free radicals we have in our body, the greater the chance that our cholesterol will become oxidized. This form of cholesterol behaves differently and is more likely to attach itself to our artery walls.

Trans fats have been well researched in recent years, and their effects on our heart are becoming clearer. Some researchers believe they are responsible for the epidemic of heart disease in the 20th Century. Trans fats have an adverse effect on our blood fats because they increase the levels of LDL “bad” cholesterol, and reduce levels of HDL “good” cholesterol. This is a double whammy; their effects on cholesterol levels are considered to be twice as bad as saturated fats. This is very unfortunate because many consumers buy foods that are labeled to be “low fat” or “cholesterol free”, and these are the types of foods that are often highest in trans fats! Trans fats are also known to raise triglyceride levels, and interfere with the metabolism of essential fatty acids in the body.

In the Nurse’s Health Study, women who had the greatest amount of trans fats in their diet had a 50% higher risk of heart attack compared to women who consumed the least amount of trans fats.

Because trans fats become incorporated into our cell membranes, they interfere with the action of insulin. They promote insulin resistance and in this way they make you fat, and increase your chances of developing Syndrome X and diabetes. Trans fats also promote the release of inflammatory chemicals called cytokines, contributing to inflammation in the body.

If you do nothing else for your heart, make sure you avoid eating partially hydrogenated vegetable oil, and processed vegetable oil that does not state it is “extra virgin” or “cold pressed”. In the USA the trans fat content of all packaged foods will need to be stated on the label by January 2006. There are no such plans in place for Australia yet, so you will have to identify trans fats yourself by looking for the words “partially hydrogenated” or “hydrogenated vegetable oil”, “vegetable oil” or “vegetable fat”. Check food labels carefully to make sure you avoid these types of fats. Healthier alternatives to use would be extra virgin olive oil, butter, ghee and virgin coconut fat. Healthy spreads for bread include avocado, hummus, tahini, tomato paste or natural nut butter/paste.

*8/53/5*

We all enjoy spending time with friends and loved ones, and in any case, the stimulation of visitors can be beneficial. There will be times when you feel the need for almost constant support and companionship. If you are experiencing a ‘low’ period and feel anxious and vulnerable then the company of a loved one or a good friend is invaluable – how often do we admit in times of stress or crisis (although usually after the event) that ‘I couldn’t have got through it without X’? At other times you may prefer to be alone with your own thoughts or to go out on your own in order to feel more independent. Your needs will vary, and while it may not be possible for family and friends always to be with you when you need them, it is helpful if they can understand when and why you need them most.

If you live alone or your wife/partner works full-time, then you will need to devise ways to ensure you have sufficient company and support. Even if you are generally happy to be alone, it is important that you do not feel isolated and unable to ask for companionship when you need it. Picking up the phone and letting a friend or relative know that you’d appreciate a visit can be hard at first – there may be some sense of admission that you can’t manage on your own, which you find difficult. This is not, of course, the case – often, people are delighted to be asked, and flattered that you have chosen them. It is very important not to let pride stand in your way! If you do usually live alone, it is likely that hospital staff will insist on arrangements to be made for your support and care before you are able to go home after treatments. This is not because they do not trust you to look after yourself, but because side-effects and problems can be unpredictable, and it is in nobody’s interest not to take suitable precautions.

From a practical point of view, you may need more support than usual with everyday tasks which you have always undertaken without a second thought, such as preparing meals or getting around and out of the house. Treatment can have unexpected effects on your physical strength and stamina, and it is important to make sure that back-up is available when you need it. This doesn’t necessarily mean you need someone to look after you full-time, although one option is to ask a relative or friend to stay with you for a time. If this is not feasible or desirable, your district nurse can arrange to visit you at home each day, and Marie Curie or Macmillan nurses can offer more specialist nursing care if you need it. Your GP can visit to check that you are coping with your medications and any side-effects. An occupational therapist can also advise on any special equipment to make managing at home easier for you.

Arrangements for both emotional and practical support may need to be more structured if you live or spend most of your time alone and can’t rely on the presence of a wife or partner. You may have to make a more conscious effort to ensure that you have all the help you need – but this does not mean that you will manage any less effectively.

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Any step into unknown territory holds fears. Starting college or a new job, moving house and visiting the dentist all cause us a degree of fear either because we don’t know what to expect from the experience and/or because we anticipate that it will be unpleasant. Dealing with cancer is certainly a league ahead in terms of the intensity of our fears, but the root cause is the same: fear of the unknown. There are so many unknown factors involved that our security is profoundly threatened:

Will I be in pain?

What is the treatment like?

Will the treatment hurt?

Will the treatment work?

What does the future hold for me?

How will my family cope?

Will my life ever be ‘normal’ again?

How will I manage to get through this?

Becoming well-informed about your cancer and treatment can help to allay certain fears: the greater your knowledge and understanding of what is happening, the more control you can take and the less uncertainty you will feel about specific aspects of your disease or treatment. However, fear is not a logical emotion and a theoretical understanding will not always prevent you from worrying. It cannot necessarily help you with more general fears – about coping or about the future, for example.

One of the aspects of cancer and its treatment which causes most fear is uncertainty: uncertainty at how effective your treatment is and uncertainty at how much of your cancer will be eradicated. Waiting for the results of X-rays or blood tests, perhaps not hearing anything for several weeks between treatments, can cause great anxiety. You don’t know what to prepare yourself for or what plans to make, you can’t stop thinking about what might or might not happen. Tension is bound to build up, however much you try to take your mind off your cancer.

After the first awful month or six weeks, it was clear that I was responding well to my chemotherapy. Following so much bad news, this was more than we could have hoped for. But there was still a very long way to go and although my tumour markers were moving in the right direction, there was no guarantee that this would continue. We anticipated each hospital visit (weekly at this stage) with a mixture of unvoiced hope and stomach-turning trepidation. Butterflies? Legions of them, all on overtime. If the details were not immediately forthcoming, it took a huge effort of will to ask, ‘What are my tumour markers this week?’ or ‘What did the CT scan show?’

Apart from immediate fears about the possible unpleasantness of treatment, thinking about the future is likely to emerge as your single greatest fear. This can encompass a whole range of ideas, from ‘How will I manage to get through my treatment?’ to ‘Will I ever get better?’ At times when you are feeling physically low, you might wonder if you can bear to undergo any more treatment or how you can possibly tolerate the effects of your cancer any longer. How will you cope if you become physically incapacitated in some way? Who will look after you? How will you manage financially? Do you fear that your family and friends will eventually tire of supporting you and that you will feel a burden to them?

Fighting against cancer shakes the very foundations of your life, and it would be unusual not to experience fears that your life is toppling around you. These thought processes cannot be banished, but you can help to keep them in perspective by sharing them with someone you trust to take you seriously and listen. There may be times when you know your fears are irrational, but you need someone to take the time to talk them through with you. You may not expect solutions to your fears, but sharing them and knowing that someone you like and respect acknowledges and appreciates your worries can make them more bearable.

Just to hear someone say, ‘Of course you’re not being stupid! I can see now how difficult this is for you’ or T hadn’t appreciated until now how cancer takes over your life’ can be enormously helpful and will help you to realize that you don’t have to face your fears alone.

Sometimes a desire to express anxiety can be inhibited by a superstitious worry that voicing fears will somehow make them come true. For example, you are anxious that your treatment might not be as effective as you’d hoped, but you daren’t say so because you don’t want to ‘tempt fate’. We know this cannot happen but it can still make us hold back from saying all we want to. Even sharing this fear can help. Nobody will think you foolish: others are likely to admit to exactly the same worry.

If you spend a lot of time alone, your fears are more likely to become magnified. Similarly, if you are not sleeping well, fears can get out of control in the middle of the night. It would be foolish to pretend that they can be avoided completely, but it is important not to allow them to take over your mind. Sharing your worries will help. It is tempting to be ‘strong’ and keep them to yourself, but the people around you will be aware of your state of mind and will want to help. It is, however, important to remember that there may be occasions when you simply prefer to maintain a ‘stiff upper lip’. There are times when this can be an equally valid coping mechanism.

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In the early stages, you may feel that you simply don’t know what questions to ask about your cancer and treatment, beyond a general sense of ‘What’s going to happen to me?’ When your doctors ask you, ‘Do you have any questions?’ it can be difficult to know where to begin, and how to put your fears and queries into words without appearing foolish or stupid. Most people are starting from a base of no knowledge at all on the subject of their cancer, so it may be most constructive to begin with some very basic questions, which you can develop as your knowledge builds up. For example:

How do your doctors know that you have cancer?

What type of cancer do you have and how advanced is it?

How does it spread and how will it affect your body and the functioning of your organs?

What type of treatment is proposed?

How long is the treatment likely to take? (weeks? months?)

What is the hoped-for outcome of the treatment (although it is never possible for doctors to give guarantees)? Is a cure or substantial remission a possibility or is the treatment palliative (aiming to alleviate but not to cure)?

How will the progress of your treatment be measured?

Who is the doctor who will be in charge of your treatment? Are there any other doctors you will see on a regular basis?

Where will you receive your treatment? Will you have to stay in hospital?

Asking a few specific questions such as these will often help to prompt further information from your doctor. It is easy otherwise for a consultation to speed by before you feel sufficiently at ease to really start talking. Remember that you don’t have to talk in medical jargon, although you do need to be clear. It’s perfectly acceptable to say, “I have a sharp pain in my stomach’ – you are not expected to be able to perform self-diagnosis. On the other hand, it is helpful if you know the names and doses of any drugs you are taking (for pain relief, anti-nausea, etc), so that your doctor can check on their effectiveness and whether any prescriptions need to be changed. This is less daunting than it sounds, as you will be given a card containing details of your drugs, which should be kept up to date. It is much easier if you can discuss these by name rather than ‘the big pink capsules’ or ‘the little yellow pills’.

The question many people consider the most important – and the most difficult to ask – is on the subject of your future prognosis. In the past, a cancer diagnosis was an almost certain death sentence, and many people still make this association immediately on hearing their diagnosis. However, treatments have progressed tremendously in recent years, and it may be that your cancer can be treated effectively. This depends, of course, on your type of cancer, how advanced it is and how you as an individual respond to treatment. When you ask about your likely prognosis, your doctor may use terms whose meaning is not obvious to you, but which have a specific connotation in this context. These include ‘cure’, ‘remission’ and ‘relapse’.

•    Cure

A cure means that all evidence of your cancer has been eliminated completely and that it will not return. How this is assessed depends on the type of cancer in question. For example, testicular cancer tends to recur within five years, and most often within two or three. So if your initial treatment is successful and a period of five years passes in which no cancer is detected, you should be considered cured. Other cancers recur in different timescales, and your doctor will be able to advise you about this.

•    Remission

Remission means that the symptoms of your cancer have disappeared or lessened, i.e. that the cancer has got smaller. A partial remission means that the cancer has shrunk by at least half. A complete remission means that the evidence of your cancer has disappeared completely and it is no longer detectable. This is not the same as a cure, as the cancer may return in the future. If it does not return within a given timespan, you may be considered cured.

• Relapse/Recurrence

This means that following your treatment, some cancer cells still remained in your body and started to grow into a detectable cancer again. It may be that these remaining cancer cells were undetectable after your initial treatment but have become active again later. This can occur in the months after treatment has ended or may not happen for some years. Your doctors will advise you about the likelihood of a relapse occurring.

You might be eager to know about your chances of achieving a cure or substantial remission, but this may be tempered by a fear of hearing bad news – for example, that only a short period of remission is expected to be achieved by treatment. Your doctors may volunteer information about the anticipated success of your treatment, based both on statistical information and the specific details of your own case.

Another term you will hear doctors refer to is the ‘stage’ of your cancer, which describes the extent, if any, to which it has spread to other parts of your body. There are four stages. Stage I means there is no spread and the cancer is confined to the primary site. Stage IV means that there is extensive spread beyond the primary site. Stages II and III fall between the two extremes.

Some people want to be kept fully informed about the progress of their treatment. You may decide, on the other hand, that you do not wish to be told too much medical detail about your cancer and treatment, especially at first. This is a very personal choice and is entirely your decision. Your doctors should be sensitive to this, although they do need to ensure that you understand what is happening during your treatment and afterwards.

It is worth remembering that while you will be looking for definitive answers to your questions, it may sometimes be difficult for your doctors to provide them. This does not mean that they are avoiding your questions, or that there are gaps in their knowledge. The treatment of cancer holds many uncertainties, and it would be wrong for doctors to be asked to provide guarantees about the future, although it is natural for you – and your family – to seek reassurance. It is useful to find out at an early stage which doctors you will have greatest contact with, so that you know who is likely to have the most knowledge about your case and is therefore in the best position to answer your questions.

In the very early stages, you may feel that you want to know as little about your cancer and treatment as possible and that additional information and knowledge are pointless because they can make no difference to your condition. This is a perfectly understandable reaction as you and your family try to come to terms with your diagnosis. As the initial shock recedes, however, you are likely to find that it is helpful to start learning a little more about your cancer. There are many books and leaflets available, covering a huge range of cancer-related topics. For some basic factual information, your hospital should be able to provide you with booklets produced by the organization BACUP (British Association of Cancer United Patients). These cover both specific cancers and related issues, such as cancer treatments and diet. Books and leaflets have a useful role as you can refer to them when you please.

If you are unclear about information you have received, you should never be afraid to ask your medical team for clarification. Similarly, don’t worry about asking the same questions more than once: when you are under stress, it is sometimes difficult to absorb information as easily as usual and your medical team will understand this.

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Radiotherapy is often given as an out-patient, if you are well enough to be at home and to travel each day to the hospital.

Planning is a very important part of radiotherapy treatment, to ensure that you receive the appropriate dose of radiation and that it is directed at exactly the right points on your body. Scans and X-rays will help your doctors to plan your treatment as these will assist doctors to establish the exact size and position of your tumour. Ink marks may be made on your skin where the radiation is to be directed, or if you are having radiotherapy to your head or neck region, then a see-through mould of the area may be constructed to keep your head absolutely still, and the ink markings will be made on this mould. The planning stage of your treatment may take some time and is likely to occupy the whole of your first appointment. It is tempting to feel impatient and natural to want to start the treatment as soon as possible. However, precise and careful planning is a vital stage of your treatment and cannot be rushed.

The dose of radiation you are to receive will be calculated precisely. It will then be split up into a number of smaller doses or ‘fractions’ which you will receive over a period of days or weeks, usually on Monday to Friday, with a recovery period at the weekend. The strength and number of doses will be tailored to your specific circumstances – your type of cancer and how advanced it is, and your general state of health must all be taken into consideration.

Various machines may be used to administer radiotherapy, either

from one or more fixed positions or while rotating around your body.

Before you have your treatment, you will be positioned very

carefully by the radiographers so that the radiation is directed at

exactly the right point. You may feel awkward if you have to hold a

slightly uncomfortable position, but the treatment itself is painless

and will take between a few seconds and a few minutes. In fact,

many people are surprised at how quickly the radiation treatment

itself is administered.

*21\118\2*

Your own doctor or oncologist is the best person to answer detailed questions about your specific cancer. However, it can be very difficult to absorb medical information which is given to you verbally when you are feeling vulnerable and possibly very unwell. This section provides some basic details of the more common cancers which affect men, by their site of origin.

It looks first at the male-specific cancers which, by definition, affect only men and cannot affect women. Although they are not necessarily the cancers which affect the largest numbers of men (these are traditionally the lung and bowel cancers), they are the cancers for which men need to have an especial awareness, in the same way that women are especially aware of breast and cervical cancers. The other cancers included in this section are those which are statistically most prevalent amongst the male population. The different cancers are covered in the following order:

prostate cancer

testicular cancer

lung cancer

non-melanoma skin cancers

cancer of the urinary tract – kidney and bladder

cancer of the bowel – colon and rectum

stomach cancer

non-Hodgkin’s lymphoma

leukaemias

Please remember throughout this section that the facts given are necessarily brief and generalized and are intended to provide you with a first step towards understanding more about your cancer. Your doctor and oncologist will be able to give you more detailed information about your cancer and recommend further books or leaflets for you to read in your own time, if you feel this would be helpful. The British Association of Cancer United Patients (BACUP – tel: 0800 181 199 and 0171 613 2121) publishes a series of booklets on different cancers, treatments and related topics. These are available free to people with cancer. Don’t be afraid to ask if you ever feel you need more information.

The mainstream cancer treatments, which are by necessity mentioned here in relation to each of the cancers discussed, are covered in detail in Chapter 3.

A glossary of the more common medical terms which you may encounter is included at the end of the book.

*7\118\2*

Learning to have pleasurable sex without intercourse is a good way to expose some myths about sex. Many men think that an erection is necessary for a woman’s sexual pleasure, but in fact it is not. A woman can experience much joy and achieve orgasm without an erect penis being in the picture. That does not mean that a woman won’t enjoy intercourse, just that ifs not always necessary. Like many of us, Caroline felt that intercourse was “real sex,” and other pleasures didn’t quite qualify. Learning otherwise made her feel better and enjoy sex more. And realizing that sex and pleasure don’t require an erection is reassuring—and re-energizing—to many men.

Once genital touching is permitted, the therapist might explain that the woman should gently caress the man’s penis until he gets an erection. Then she stops touching until the erection goes away—without the man ejaculating. The lovers can then repeat the exercise. Doing this several times gives the man practice in getting, losing and regaining an erection. It’s reassuring to both partners to realize that an erection once lost is not gone forever.

Or the man might caress the woman. Some men have always been the more active partner in sexual encounters, and they may find it difficult to relax and let their partner give pleasure to them, as the exercises require. One way around this is for the man to caress and stroke his lover first. Initiating the exercise may make it easier for him to then let his companion take the lead.

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To diagnose leaky veins you often need to have a cavernosogram. This test has been around for a while, but recently if s become more widely used to check out vein problems. It can provide important information which just isn’t available any other way.

The cavernosogram test takes about 20 minutes, and while it involves sticking a small needle in your penis, it is an otherwise painless procedure. You are given an artificial erection with a penile shot. The doctor then injects some dye into the penis which makes any leaky veins show up on an X-ray. If everything is normal, the dye should just stay in the erect penis. But if a man has leaky veins, the dye will leave the penis and show up in the veins. With this test, your doctor can determine the size and location of the leak.

Another test, the xenon wash-out, gives some of the same information but unfortunately can’t pinpoint the location of the leak. Because the cavernosogram gives more information, if s usually preferred.

The crucial thing about vein abnormalities is that they can be exceedingly difficult to diagnose. If a doctor doesn’t look for them, vein problems are easy/to miss. Any leak in the system may be a lifelong problem, or it may develop after years of satisfactory erections. Eric, a 40-year-old fisherman, had always enjoyed sex very much. He never had problems with erections. A large and very strong man, he prided himself on his health and the effort he put into keeping physically fit. But two years ago, Eric developed a problem maintaining his erections. He didn’t know what was wrong and neither did his steady girlfriend, Margie. As time went on, Eric’s difficulty increased. He went to several doctors, but no one could find anything wrong with him. Finally, Eric was referred to a urologist who specialized in potency problems.

Sure enough, Eric checked out fine on every test—but one. That test showed that he could blame his veins for the change in his potency. At this point, we don’t know just what makes some veins fail after functioning well for years. Fortunately, Eric didn’t have to resign himself to the situation. He had a choice between having the veins repaired, or having a penile prosthesis.

*136\184\8*

There are lots of self-help sexual aids on the market, many of which are sold with the claim of fantastic powers. While some of them do work for some men, you should never use any of these devices without first consulting your physician. You need to find out if your potency problem is caused by a medical condition, which in itself requires treatment. Consulting a doctor before you buy anything might also save you a lot of money, disappointment and even harm to your health.

Cock Rings

One common aid used to boost potency is the cock ring— and it does work for some men. After a man has attained the best erection he can, the cock ring will hold the blood in the penis to keep it erect. These rings may be helpful for men who can get an erection but have difficulty maintaining it. But used improperly, they can cause pain and even permanent damage. A man who cannot become erect at all usually will not find them helpful.

Cock rings are sold in sex shops and by mail order houses. They are often made of thick rubber like material, which stretches easily so the ring can be slipped around the base of the penis once an erection is present. The rings come in different types of designs; some even have bumpy areas to stimulate the woman’s clitoris.

If, after consulting your physician, you decide to try a cock ring, it is essential that you observe precautions. You should use the ring only for short periods of time—never over 30 minutes. This is very important, because otherwise the penis can swell and make removal difficult and painful. Think of how your finger swells if a too-tight ring is left on.

So, clearly, being able to get the ring off easily is of prime importance. Some rings stretch easily for removal, others have snaps which you have to unfasten. Only use rings which can easily and quickly be removed or cut off. If you can’t get a ring off, it can cut off the blood supply, which can cause gangrene and possibly require amputation of the penis. Therefore, plastic, wood or metal rings, or thin elastic or rubber bands which can be lost in the skin and difficult to remove, are absolutely not recommended. One man kept a metal cock ring around his penis for several days. When this unfortunate fellow finally came into a hospital emergency room, the ring was literally cutting into his penis, causing profuse bleeding. It took a special saw to cut the metal and remove the ring.

If you have pain, your penis feels tender or you see any type of discoloration on the organ, remove the ring immediately. And if any of the symptoms or discomfort persist after removal, see your physician without delay.

And we hasten to add that a man with poor sensation in his penis should never use a cock ring, because he won’t feel the warning signs that tell when a ring is causing damage.

*108\184\8*

It’s important to know that after either type of prostate surgery, a man will retain his ability to feel an orgasm, but he won’t ejaculate any fluid. Because the prostate produces part of the fluid a man ejaculates, after surgery he has less fluid to discharge; what does come out goes back into the bladder. This isn’t harmful, and the ejaculated fluid simply mixes with urine and is discharged when the man voids.

Some research suggests that just knowing what to expect after prostate surgery can help a man keep his potency. So here’s our advice for prostate patients.

• Be sure you understand why the doctor is recommending prostate surgery.

• Specifically, ask how it will affect your sexual functioning. Make sure you get a clear and comprehensive answer.

• If you’re having a radical prostatectomy, make sure your doctor is familiar with the new nerve-sparing methods. Some large tumors cannot be treated this way; if your physician advises against the new techniques, be sure you understand the reasons, Make sure you understand the pros and cons of any alternative treatment.

• Make sure your wife understands the procedure and the amount of time it will take you to recover. Encourage herto discuss with you and the doctor any concerns she may have.

For those patients who do lose potency after prostate surgery, penile prostheses or penile shots (discussed in chapters 7 and can enable a man to get and maintain an erection.

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Many drugs can interfere with erection. Here is a list of the more common troublemakers. In some cases doctors aren’t sure if the drug is really causing the problems; with almost all of these drugs, some men may experience potency problems while others remain unaffected. If you think one of them may be contributing to your erection problem, consider switching to another drug or type of treatment. But be sure to talk over any change with your doctor first. Stopping a drug treatment on your own can be dangerous.

Fortunately, the negative effects of drugs on potency are almost always reversible, though it may take some time for your system to get back in gear after you quit taking the drug.

Generic Name Brand Name

Blood pressure medicines and

diuretics

Thiazides Diuril, Esidrix,

Hygroton and

others

Spironolactone Aldactone

* Hydralazine * Apresoline

* Minoxidil * Loniten

Methyldopa Aldomet

Clonidine Catapres

Reserpine Serpasil, Sandril

Guanethidine Ismelin

Bethcmidine

Pargyline Eutonyl

Phenoxybenz- Dibenzaline

amine

*50\184\8*

The bloodstream transports gases throughout the body. Blood is pumped into the lungs, where it deposits carbon dioxide, a waste product, and receives oxygen. The fine balance and control between the heart and lungs prevents shortness of breath even when you exercise. Shortness of breath (dyspnea) that occurs at rest or with little exercise can be acute or chronic, but in either case it is caused by diseases of the heart or lungs, or both. Occasionally, illnesses such as anemia or excess thyroid hormone (hyperthyroidism) tax the heart so that it must work overtime. The result is shortness of breath.

Sudden breathlessness can occur without warning, and it can be frightening. You may feel that you are choking because you are unable to catch your breath. Depending on the cause, there may also be pain in the chest, cough, heart palpitations, dizziness, light-headedness, and mental confusion.

One of the common causes of sudden breathlessness is heart failure. Acute heart failure, or pulmonary edema, means that the pumping action of the heart suddenly becomes impaired. Instead of the heart being able to effectively pump the blood that has been brought to it, the blood backs up and collects in the lungs, thereby interfering with the exchange of oxygen and carbon dioxide.

The common causes of acute heart failure are heart attacks (myocardial infarction), a sudden irregularity of the heart rhythm (cardiac arrhythmia), or conditions that suddenly overtax the heart, such as severe anemia, hyperthyroidism, or a pulmonary embolism. Immediate emergency-room care and hospitalization are required for heart failure. Medications such as diuretics, morphine, and digoxin are used because they drain the fluid from the lungs and improve the efficiency of the heart’s pumping action. An electrocardiogram, chest X-ray, and blood tests may be necessary to find the exact cause and best treatment for this condition.

Even though the pulmonary (lung) causes of sudden breathlessness can be as dramatic as the cardiac (heart) causes, in most cases lung causes are more gradual, even during an acute situation.

A collapsed lung (pneumothorax) can also cause sudden breathlessness. In this situation one of the small air sacs in the lung ruptures, and air rushes out of the lung and into the pleural space between the lung and the chest wall. The lung loses air and collapses. Sometimes there is sudden pain with the episode. Chronic bronchitis and emphysema are often responsible for a collapsed lung. Immediate medical attention is required to allow the lung to reexpand.

Other common respiratory causes of sudden breathlessness are infections such as acute bronchitis or pneumonia. You may not know that you have these diseases until an attack of acute breathlessness occurs. You may have had a recent cold or flu with some cough, phlegm, or fever. Sometimes a rapid progression of symptoms occurs within a few hours and you may become short of breath. The most important clue to a lung infection is coughing and yellowish or green phlegm.

Another condition that causes shortness of breath is a pulmonary embolism. A blood clot (thrombus) forms either in the veins of the legs or pelvis and makes its way to the heart and lungs. The clot blocks the blood flow from the heart to the lungs and interferes with breathing. Other symptoms can be chest pain and coughing up blood. This is a medical emergency that requires hospitalization and rapid treatment with anticoagulants (blood thinners) to prevent further blood clots from forming. Very rarely, emergency surgery is done to remove the blood clot from the lungs.

You are most at risk for pulmonary embolism if you have had surgery or have suffered from a severe illness that has required prolonged bed rest. Operations and fractures, especially when occurring after an accident, pose the greatest danger. However, there is a good chance for a complete recovery. I treated a spry 93-year-old woman who had fractured her hip. She agreed to hip surgery and was doing well until three days after the operation, when she suddenly developed severe pain in her chest and became short of breath. She was diagnosed as having pulmonary embolism. Despite her age, she made an excellent recovery. Three years later, she is still an active, involved, and very independent woman.

A number of less common events can cause sudden breathlessness. In some, following an inflammatory illness or viral infection, the lungs accumulate excess scar tissue. The body tries to counteract the inflammation and produces a jellylike material which fills the lungs and interferes with their proper function.

Inhaling a noxious material during a fire or breathing some chemical that may inflame the lung can also cause sudden breathlessness.

In most cases of sudden breathlessness, hospitalization is required for proper investigation and treatment. First-aid measures by a physician or in an emergency room can be life-saving, such as expelling the air from the chest in a case of pneumothorax, improving the severe fluid congestion in heart failure, or giving oxygen after removing a person from a smoke-filled room. Most of these conditions respond to treatment, but urgent medical attention improves the chances of recovery.

Unlike the sudden causes of shortness of breath, the chronic causes may be gradual and therefore more insidious. It may take many days, weeks, or months before you are aware that you no longer can undertake your normal activities because of shortness of breath.

If you have heart disease, you may discover that you pant after exertion. You might feel short of breath lying in bed, especially when you lie flat, and find that raising the head of your bed or using more pillows makes you comfortable. Sometimes you become breathless only in the middle of the night. Getting up and walking around sometimes helps. You may begin to notice that your legs swell, which is usually worse at the end of the day. This edema can be so gradual that you may not be aware of it.

If you have not had a heart attack or rheumatic fever, you may not be aware that you have heart disease. Some people know only that they had high blood pressure for many years before the symptoms of chronic heart failure show up. If you begin to experience these symptoms, heart failure might be diagnosed. Your physician will usually do a number of tests, including a chest X-ray, an electrocardiogram, and blood tests. Treatment, often with a combination of medications, is usually successful.

Like chronic heart failure, chronic pulmonary breath-lessness progresses gradually, often occurring with a cough, excessive phlegm, or wheezing. Sometimes there are no symptoms other than the awareness that physical activity has become more difficult.

Shortness of breath from lung disease is more common if you smoke. This is by far the most common cause of chronic respiratory disease. Unfortunately, many people continue to smoke even though they know the connection between smoking and their symptoms. You may have had wheezing and coughing for many years, or other symptoms that signify the development of chronic bronchitis and emphysema.

Exposure to lung irritants from work, such as occurs in miners, grain handlers, and people who worked in dusty atmospheres for many years or with irritant chemicals can also cause chronic lung disease and chronic breathlessness. Your work history should be given to your doctor when you discuss your history and respiratory symptoms.

As in heart failure, with pulmonary disease you may notice some swelling in your legs, especially if the disease is severe. You may learn to partially close your lips as you walk which makes breathing seem easier, and notice your hands tend to be gray or blue. You may have little tolerance for cold weather, which often aggravates breathlessness. Tests for these symptoms include a chest X-ray, an electrocardiogram, and pulmonary function tests, which allow the physician to determine the cause and extent of the lung damage and measure the response to treatment.

On rare occasions your physician may recommend a lung biopsy, in which a small piece of lung tissue is removed and examined under a microscope. This facilitates a diagnosis that may have been difficult to determine by other means.

Another condition that causes breathing difficulty is pleural effusion (an accumulation of fluid between the lung and chest wall). Often, the physician can remove this fluid to relieve symptoms and diagnose the reason for its accumulation. The causes include heart failure, infections, inflammatory diseases, and tumors. Thoracentesis (removal of fluid) is usually painless and has very little risk.

Occasionally, a pleural biopsy may be necessary, in which a needle is inserted to remove a small piece of the pleura (lining of the chest wall). This is simpler than a lung biopsy, and it helps to clarify the cause of fluid accumulation.

Most people with chronic lung disease causing breathlessness can be helped if medical advice is followed. Stopping smoking is the single most important step you can take.

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Losing your appetite can be very discouraging, and it is a common complaint of older people. You may ask your doctor or pharmacist for a “tonic” to improve your appetite. But a “tonic” that consists of a mixture of vitamins and alcohol acts for a short period only as a placebo.

A decreased or lost appetite can be caused by various physical and psychological illnesses or it may be a side effect of medication. Digoxin, used for heart diseases, can accumulate in your body and lead to digitalis toxicity, which often results in a loss of appetite. Other medications that can lead to appetite loss include antibiotics, especially tetracycline and erythromycin, and drugs used to treat Parkinson’s disease, heart palpitations (irregular heart rhythms), or abnormal emotional states.

in addition to drugs many illnesses can lead to a loss of appetite, including those that affect the stomach, bowel, liver, and pancreas. Diseased kidneys may cause a gradual loss of appetite, as may an underactive or overactive thyroid gland and metabolic disturbances affecting the body’s control of calcium.

A major cause of appetite loss is depression. This illness may not be immediately recognized by you, your family, or your physician because the symptoms are often different from those in the younger person. If you think you are suffering from depression, consult your physician, who can prescribe or arrange for suitable antidepressant therapy.

You should always be aware of social situations that interfere with your desire to eat. If you live alone, you may lose interest in preparing food or you may not want to eat because you have no one to share a meal with. This situation is similar to depression, but it can be treated by finding friends or neighbors to share meals.

Although as you get older your needs for food may decrease, you should not confuse this with appetite loss. If your weight remains steady, there is usually little to worry about. When loss of appetite is severe, it usually causes weight loss, which should be evaluated by a physician.

One 93-year-old woman caused great concern for her daughters because she ate very little according to their standards. They said she only nibbled at her food, whereas she claimed that she ate all that she needed. She remarked, “At my age you don’t need much food.” A comparison of weights taken at my office showed that her weight had not changed in the last two years. Clearly she knew what she was talking about.

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Heart function can be evaluated in a number of ways. A physical examination and a chest X-ray are crucial. However, different types of electrocardiograms (ECGs, sometimes abbreviated EKGs) give information that cannot be obtained by any other means.

A muscle in the heart receives its stimulation from an electrical system that governs how the heart beats. An electrocardiogram records the contraction of the muscle and the electrical impulses. By studying the ECG patterns and changes, physicians can diagnose many heart disorders.

An ordinary electrocardiogram takes about five minutes and is completely painless and has absolutely no danger. It is done either routinely to make a record for future reference or at the time of a suspected heart disturbance. Because an electrocardiogram records only a few moments of your heart’s action, it may fail to reveal abnormalities that occur infrequently or episodically, such as an irregular heart rhythm. It may be necessary, if you have had a heart attack or have an irregular heart rhythm, to repeat tracings frequently to observe any changes.

Your physician may want to have an ambulatory cardiogram, which means you carry a small, portable recording device (called a Holter ambulatory monitor) that continuously traces your heart’s rhythm over an extended period, usually twenty-four hours. This monitor is more likely than an ordinary ECG to reveal an episodic change in heart rhythm that may be the cause of dizziness or fainting spells. Although somewhat less convenient than a standard ECG, this tracing over time can supply invaluable information about the cause of unusual symptoms. Sometimes the attacks are so infrequent that it may take more than one tracing before the diagnosis can be made. It may also be repeated to see if treatment is effective.

Some people have chest pain that is not typical of angina pectoris. The standard ECG, which is taken while you are resting, may not reveal any abnormalities, so cardiographic tracings may be taken while you exercise in a carefully controlled situation. This is called an exercise or stress ECG. The tests involve riding a stationary bicycle or walking at increasing speeds on a moving ramp. Electrocardiogram wires will be attached and a technician and a physician will supervise the examination and interpret the results.

The only danger of this test is that you may experience an episode of angina pain during the procedure. However, it is certainly safer to have an attack under supervision so that a definite diagnosis can be made than to experience attacks when you are alone. Sometimes this test may be repeated after you have been given treatment for your anginal symptoms or after a heart attack.

The results of this test are not completely foolproof. You may have a normal test and still suffer from coronary disease. Occasionally, a test appears to indicate heart disease in a person who is normal. The examination itself is only one part of the total evaluation of heart disease. Your doctor will interpret all the tests together before he makes a diagnosis and decides on treatment.

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Angiography is a relatively new development in the field of radiology. An angiogram is an X-ray taken while an iodine substance is injected into blood vessels. This reveals any abnormalities in the organs that they supply. Angiography can be used to visualize the blood supply of every organ in the body. With little danger, many internal parts of the body can be outlined by the pattern of the blood vessels. Diagnoses that were previously elusive are more easily made with the assistance of these X-rays. The only discomfort is that of the needle entering the blood vessel and the momentary warm feeling that may occur when the iodine enters the body. Very rarely people who are allergic to the iodine dye may suffer anaphylaxis (shock) which may be fatal.

Angiograms are done of the carotid blood vessels (blood vessels to the brain) in patients suffering from strokes. An angiogram may show the reason for the stroke and may help determine whether treatment can relieve symptoms or prevent further strokes. Other abnormalities of the brain can be shown with a cerebral (brain) angiogram, such as benign or malignant tumors and blood clots (hematoma), which occasionally press on the brain. Clots may be found in older people who have suffered a fall.

A peripheral angiogram indicates whether there is a blockage in the blood vessels to the legs. A vascular (blood vessel) surgeon might be able to bypass such a blockage or remove a clot that has formed.

An abdominal angiogram outlines the arteries and veins that supply the large and small bowel. Occasionally, older people bleed from various parts of the bowel, and this may not show up on barium X-rays. In these cases an abdominal angiogram may demonstrate the area of hemorrhage and the exact site of blood loss, especially if done at the time of active bleeding.

A cardiac (heart) angiogram shows the blood vessels supplying the heart. This X-ray is suggested for patients who have angina pectoris or who have had heart attacks (myocardial infarction), if the physician is considering a bypass operation to increase the heart’s blood supply.

All angiograms have a small degree of risk. The main danger is bleeding from the site of insertion of the thin plastic tube (catheter) that is used to inject the dye into the blood vessel. Blockage of the blood vessel, which occurs very rarely, usually means that the underlying disease is severe. In most cases the minimal risk of the angiogram is less than the danger of the disease. I have recommended these tests to many elderly patients and have rarely observed serious side effects.

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Urine, which is produced by the kidneys, contains a large amount of water, within which the body’s waste products are dissolved. Infections that occur in the urinary system can lead to abnormalities in the urine. If the kidneys are damaged, the normal amounts of elements in the urine are altered. During illnesses such as diabetes mellitus, sugar may “leak” into the urine. Its measurement can be useful in controlling the degree of blood sugar elevation.

Some urine tests require only a small sample of urine. Other tests require a whole day’s urine, sometimes collected in a special container that contains a preservative to keep it from decomposing. It is sometimes necessary to bring the first urine passed in the morning.

When the physician checks your urine for signs of infection, it must be collected in a way that keeps the bacteria in the urine from being contaminated by the bacteria on your skin. Urine collected in this way is called a midstream urine (MSU) or clean-catch specimen. Such a sample requires a sterile container so that only the germs in the urine are examined.

In men it is usually easier to collect a clean-catch specimen. As the man urinates into the toilet, and while the stream is flowing, he can place the sterile container under it without interrupting the flow.

In women, bacteria normally inhabit the area around the urethra. If these enter the container with the urine, the test results may wrongly suggest an infection. It is therefore necessary for women to clean the area around the urethra and vagina with sterile water before collecting the urine. Then, as the urine flows, while standing over a toilet, the specimen is collected in a sterile container without interrupting the stream. In older women with physical disabilities or who are unsteady, it may be necessary for a technician or nurse to help obtain a clean-catch specimen.

The stools may be tested for bacteria or parasites if there is a suspicion of infection, for example, if you experience severe or prolonged periods of diarrhea. Sometimes the stools contain bright red blood if bleeding from the colon or rectum has occurred. If there is significant bleeding from the stomach, the stools may become black and look like tar (tnelena). Small amounts of blood in the stool may not be visible to the naked eye; this is called occult bleeding. Such bleeding may cause anemia. Special tests are used to check stool samples for occult blood. In order to diagnose bowel malignancies at an early stage, some physicians recommend that older individuals take stool samples at home and apply them to home testing kits which can then be brought to the physician for analysis.

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Definition

Pruritis vulvae is marked and persistent vulval itch without apparent primary cutaneous cause. The vulval skin, particularly on the labia, is lichenified and there may be secondary infection, inflammation or local tissue reaction.

Investigation and diagnosis

Primary infective inflammatory and dermatological conditions should be excluded before the diagnosis is made. Differential diagnosis includes HPV infection, vulval intraepithelial neoplasia (VIN) and non-squamous metaplasia.

Management

Avoid vigorous washing with soap. Periodic bathing in saline and the application of bland creams may alleviate symptoms. Hydrocortisone 1% cream can be used for severe episodes but prolonged application of steroids may lead to atrophy.

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Paediatric infections are usually asymptomatic; infected children are more likely to become chronic carriers. Symptomatic infection is less likely to lead to a chronic carrier state.

The incubation period is from 60 days to 6 months. Acute illness frequently presents with malaise, nausea and vomiting. Other symptoms may include arthralgia, rash, myalgia, headaches, photophobia, pharyngitis, cough and coryza. Dark urine and light coloured stools precede jaundice by 1 to 2 weeks and jaundice usually persists for 1 to 4 weeks. Tender hepatosplenomegaly may be noted.

Infection, whether asymptomatic or causing an acute illness may be followed by recovery, a carrier state, chronic hepatitis or cirrhosis. Primary hepatic carcinoma may be a late complication.

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Donovanosis is a mildly contagious, chronic progressively destructive infection caused by Calymmatobacterium granulomatis, a gram-negative, oval bacillus in which polar bodies are often prominent. The organism develops intracellularly and is difficult to culture. This disease occurs in tropical countries including Papua New Guinea and, although uncommon in Australia, appears to be endemic in Aboriginal people in northern and central parts of the country.

Donovanosis should be distinguished from other causes of genital ulceration including syphilis, chancroid, lymphogranuloma venereum, severe herpes, cutaneous amoebiasis and anogenital neoplasm by appropriate tests. The diagnosis is established by the demonstration of С granulomatis in smears from scrapings or biopsies from lesions. Smears can be made by pressing a clean glass slide on the cut surface of a biopsy. The organisms can be identified as bipolar rods in large mononuclear cells and are best seen in giemsa-stained smears.

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Penicillin susceptible infection

Amoxycillin sodium 1 g intravenously every 6 hours until oral amoxycillin (500 mg 3 times daily for at least 7 days) can be given. Patients (other than pregnant females) who are sensitive to penicillin can be treated with spectinomycin (see below). Pregnant females should be treated with erythromycin

Penicillin resistant infection (first line treatment where PPNG is endemic) Cefotaxime 0.5 to 1 g intravenously three times daily for at least 10 days or Ceftriaxone 1 g intravenously once daily for 7 days or Spectinomycin 4 g in a single intramuscular dose daily (Dose may be divided between 2 gluteal sites).

Gonococcal conjunctivitis

Untreated gonococcal conjunctivitis in neonates is highly contagious and may rapidly lead to blindness. Systemic antibiotics are required e.g.:

Benzylpenicillin 30 mg/kg intramuscularly every 6 hours for 3 days (for penicillin sensitive infections) or Ceftriaxone 25-50 mg/kg intravenously or intramuscularly daily for 3 days (for PPNG) for 7 days or Spectinomycin 40 mg/kg intramuscularly daily for 3 days (for PPNG).

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An equivalent criterion for the diagnosis of cervicitis is the presence of 15

to 20 or more polymorphonuclear leucocytes per oil immersion high power field in 5 or more fields in a satisfactory area of a properly prepared cervical smear. This is not valid during menstruation when large numbers of polymorphs are normally present.

Swabs from the endocervical canal, urethra and anal canal should be examined by smear (gram stain) and culture for the presence of polymorphonuclear leucocytes and gonococci.

For chlamydia, swabs from the endocervical canal and urethra should be examined by smear and direct techniques; culture is only available in some larger centres. Good specimens are important for the diagnosis of chlamydia. Swabs should be taken from the cervical mucosal surface under direct vision. A cytobrush can be used to obtain good specimens.

Swabs of the lateral vaginal wall are suitable for examination by smear and culture for yeasts. Swabs of the urethra or posterior vaginal fornix can be examined by wet mount or culture for trichomonads.

Swabs of vesicle fluid and the ectocervix may be examined by direct microscopy, immunofluorescence or culture for herpes simplex virus.

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