broken hearts

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don't break my heart

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Heartbroken is just a word we use but did you know that hearts could really be broken? Till recently, even doctors did not take broken hearts seriously.

Around ten years ago, there were a few high profile deaths in young people. They were diagnosed as having died from a "broken heart". Now, a broken heart or stunned myocardium syndrome (also called takotsubo) is a documented condition. It occurs as the response of the heart to sudden, intense emotional stress such as the death of a spouse; rejection at the workplace; acute fear; or uncontrolled anger. These intense emotions can cause immediate breathlessness or strokes. The broken heart can occur simultaneously or a few minutes later.

The sudden surge of uncontrolled emotions causes the release of two chemicals, adrenaline and nor adrenaline. These help the body ready itself for a "fight or flight" reaction. Sometimes, there is an abnormal elevation of these chemicals. This causes the cardiac arteries to narrow, decreasing blood flow to the heart. The adrenaline binds to the heart muscles, causing a large number of calcium ions to enter the cells and skewing the balance among calcium, potassium and sodium. The muscle becomes dysfunctional. The affected areas start to balloon out. The lower-most part of the heart (the apex) has the least blood supply so it is most affected.

The symptoms are similar to a heart attack - chest pain, sweating, giddiness or dizziness, nausea, vomiting, weakness and palpitations. Blood pressure may drop. Heart failure may develop.

The ECG changes are atypical, with imprecise changes in the ST segment and T waves. They are "suspicious of but non conclusive" of myocardial infraction. Blood tests for the enzyme creatine kinase and proteins troponin should be done. These are elevated in a heart attack. In a stunned heart, these results too are inconclusive. The echocardiogram is the clincher. The heart is ballooned out. This change occurs typically at the apex of the heart. It is important to make a distinction between heart attack and takotsubo as the medication is different.

The treatment for takotsubo is mainly supportive. Medication is given to remove fluid from the lungs and prevent clots. Recovery occurs within a few days.

About two per cent of people who were thought to have a heart attack actually had broken hearts. In the case of women, this increases to seven per cent. Women, mainly menopausal ones (60-75 years), have "broken hearts" eight to nine times more often than men. Some people are genetically prone to "broken hearts." Depression plays a role in susceptibility to this condition. Recurrences can occur in 10 per cent of people.

People who are in poor physical condition do not need severe emotional stress to suffer a broken heart. An episode may be precipitated by a minor event like rejection, or even a lecture or talk before an audience.

In order to never develop this condition; it is important to develop metal and physical toughness. Walking for 40-60 minutes a day at a brisk pace exposes the heart to small doses of adrenaline and nor adrenaline in a controlled manner. The heart gets conditioned and is immune to sudden chemical surges. Meditation and yoga provide calmness and the mental strength to cope with good days and bad.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

contraception

http://www.telegraphindia.com/1141124/jsp/knowhow/story_19078544.jsp Let’s talk of contraception Your Health DR GITA MATHAI Since it is the woman who has to carry a baby for 40 weeks — with its attendant nausea, food fetishes, backache and swollen feet — she should have a right to choose when she wants to have children and how many. This is where prevention of pregnancy or contraception comes in. There are 15 or more methods of contraception available internationally. They are both temporary (for spacing) and permanent. Most require access to clinics and medical personnel. Understanding each method and choosing the correct one requires intelligence and some level of education. Sterilisation (tubal ligation) involves tying off the tubes leading to the uterus. This is a short surgical procedure, which requires only local anaesthesia. Though it is a “permanent” method, it can be reversed with a 40-80 per cent success rate. Men can also have surgical and even “non-scalpel” vasectomy. Reversal is successful in 50 per cent cases. The procedure in men is simpler and less prone to complications. Despite that it is not very popular. The oral contraceptive pill is 99.9 per cent effective if used correctly. A medical check up should be done before starting “the pill” and yearly after that. Fertility returns within 3-5 months of stopping the tablet. Rings impregnated with estrogen and progesterone can be inserted into the vagina. They have to be removed after three weeks and a new ring reinserted a week later. Hormonal patches (Ortho Evra) can be stuck on the skin. They need to be changed every week. Injections of long acting progesterone can be administered every 12 weeks. They may cause some weight gain and irregular bleeding. Implants are small, hormone-impregnated rods that can be inserted beneath the skin under local anaesthesia. They need to be replaced every three years. Intrauterine devices can be inserted into the uterus and left there for periods varying from three to five 10 years. A medical professional needs to insert and remove them. The I-pill or morning after contraceptive is used for unexpected unprotected intercourse. The pill should be taken within 72 hours. Since it contains a high dose of hormones it should be used for emergencies only. It is not suitable for frequent use. Condoms are available for both men and women. They should be used from the beginning to the end of intercourse. Their effectiveness increases if used in combination with spermicides like Today or Durafoam vaginal tablets, Delfen or Volper cream. Diaphragms, cervical caps and sponges can be inserted just before intercourse. They can be combined with spermicidal jelly or foam. Women need to be fitted with a device of the correct size and taught to insert it. It needs to be left in place for at least six hours after intercourse. It is washed, dried and used again. If any of these contraception methods fail, pregnancy can occur, even in breast-feeding mothers or women who have not yet had their periods after childbirth. Abortion is legal in India and can be surgical or medical. There are protocols in place for the use of surgery or tablets for safe abortion. Please do not purchase tablets over the counter or attempt abortion without medical guidance. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

Bless you! http://www.telegraphindia.com/1141117/jsp/knowhow/story_19048878.jsp#.VG64v4vLe9g Your Health DR GITA MATHAI Winter brings in its wake runny noses, sneezing, itchy eyes and sometimes even wheezing. Is it the flu? Or is it allergic rhinitis (a runny nose caused by allergy)? Distinguishing between the two is sometimes difficult. But remember there is always fever with flu whereas in allergies there is no rise in temperature. Allergies occur because the body reacts to foreign particles — pollen, dust, cockroach dander, birds, cats, dogs or even strong odours like room fresheners, paint and mosquito repellents. As soon as the allergen comes into contact with the lining of the nose, IgE (immunoglobin E) is produced. This attaches itself to mast cells present in the nose. In an attempt to rid the body of the offending compound, the mast cells release histamine and other inflammatory chemicals. These are responsible for the symptoms of allergy. The eyes and nose water, and there may be incessant sneezing. IgE is specific; each type is produced in response to a particular allergen. This is why some people are allergic to cats and others to paint. Some people are not allergic at all as their IgE levels are low. The tendency to have allergies runs in families. Some people are unfortunate and sneeze all year round. They have perennial rhinitis with chronic nasal congestion. Perennial rhinitis increases with age as the nasal mucous membrane progressively becomes thin and dry. Also, constant exposure to irritants like cigarette smoke and air pollution can cause the nasal passages to become irritated, engorged and leak fluid. Estrogens can cause nasal congestion and sneezing. This may be distressing during pregnancy or during certain phases of the menstrual cycle. Synthetic estrogens (in oral contraceptives or hormone replacement therapy) can produce a similar effect. Other medicines like antidepressants, sedatives like alprazolam and blood pressure medications can cause nasal congestion as a side effect. To keep allergies away: • Avoid obvious allergens like cigarette smoke and strong odours • Keep the house dust and mold free • Make sure that pests like cockroaches or bed bugs are eliminated • Wash the nostrils morning and evening using a solution of half a teaspoon of salt and a pinch of baking soda in a cup of water • Spay the nostrils with a non absorbable steroid spray morning and evening • Take steam inhalations Antihistamines are the mainstay of therapy for allergic rhinitis. They dry the secretions so that the symptoms disappear. The older antihistamines like diphenhydramine (benedryl) caused drowsiness, but the newer second generation antihistamines are much better. Leukotriene antagonists like montelukast can be used in combination with antihistamines for added benefits and quicker results. If the symptoms are very severe then it may be possible to identify the allergen. There are centres that specialise in allergy testing. The skin is pricked and exposed to small amounts of suspected allergens. If a bump appears at the site of testing, the test is positive. Desensitisation is attempted by injecting increasing doses of the allergen at specific intervals. A third of the patients benefit to some extent but many require maintenance injections. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

pelvic pain

http://www.telegraphindia.com/1141103/jsp/knowhow/story_18992189.jsp#.VF3JNjSUea8 Pelvic pain Your Health DR GITA MATHAI Many of us suffer from pelvic pain. Although common, it is a poorly understood disease. At best it may be described as a discomfort somewhere below the umbilicus and above the pubis. It may be constant or intermittent, dull or sharp, and aggravated by sitting or standing for long periods. Lying down usually brings relief. The condition is called chronic if it is present for six months or more. However, such pain should not be confused with dysmenorrhea — the pain that accompanies menstruation — or pregnancy pains. Pelvic pain has many causes. In women, it may be due to a pelvic infection. Organisms such as bacteria, viruses, chlamydia or spirochetes may affect the body. The infection may not have been treated or may have been inadequately treated, resulting in chronicity and adhesions. Endometriosis is another reason. This is a condition where the endometrium, a tissue that forms the inner lining of the uterus, grows outside it — in the pelvis and abdominal cavity. But it behaves as though it were in the uterus and bleeds during the menstrual cycle. As this blood cannot exit the body, it breaks down wherever it is and forms adhesions and scars that distort the pelvic architecture. This can cause severe pain. The cause may also lie in the urinary bladder (cystitis) or in the bladder wall (interstitial cystitis). There is pain if the bladder is full. Sometimes, pelvic pressure or pain is felt if the person suffers from irritable bowel syndrome (IBS). Then there may be uncomfortable or painful bloating, with constipation or diarrhoea. Another reason is pelvic congestion, which is due to enlarged veins. This can be picked up by doppler or ultrasound studies. In men, pelvic pain may be due to urinary tract, bladder or prostrate problems. Urinary tract or acute prostate infections can be identified and treated. Chronic prostatitis is difficult to diagnose and treat. The infecting organisms are tough to identify. Prolonged treatment with antibiotics like quinolones (ciprofloxacin) or Septran may be needed, although the symptoms may persist. A pelvic examination helps identify infections, tumours or an enlarged prostate. There may be trigger areas which when pressed produce the pain. Cultures of urine from samples taken by prostatic massage, from the cervix or vagina may grow bacteria. An ultrasound will estimate the size of the pelvic organs and tumours, if any. If nothing shows up, X-rays and CT scans or MRIs may be done. If all the tests are negative, a laparoscopy may be needed to see into the pelvis. While diagnosis is pending, one may explore other avenues. Sitz baths — sitting in a basin of warm water for 10 minutes two or three times a day — often help. Another technique is alkanisation of the urine with alkalising solutions got from the pharmacy. Or else dissolve a teaspoonful of baking soda (sodium bicarbonate) in a tall glass of warm water (300ml) and drink it at bedtime. Those who have high blood pressure or are on salt-restricted diets cannot do this. The trigger points on the abdomen may be numbed by applying ice packs. Sometimes a local anaesthetic can be injected to provide temporarily relief. The sensation of pain travels through nerves up the spinal cord to the brain. Mild antidepressants like amitriptyline and gabapentin can block these transmissions and relieve the pain. They are especially effective if combined with anti-inflammatory medications like ibuprofen. IBS and food allergies should also be tackled. Sometimes avoiding milk or wheat or both, and tackling abnormal gut motility works. Physical activity reduces pain to an extent. Walking, jogging or running for 40 minutes a day is important. This should be combined with stretching and pelvic exercises. And if there is stress, cut it down with yoga and meditation. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in Share on emailShare on printShare on facebookShare on twitterMore Sharing Services

http://www.telegraphindia.com/1141027/jsp/knowhow/story_18967972.jsp#.VFYA34vLe9g Sleep, sweet sleep Your Health DR GITA MATHAI Good night • Avoid caffeine in any form after 2pm • Do not consume tobacco and alcohol • Walk, jog, run, swim or cycle for 40-60 minutes a day • Stop all exercise three hours before bedtime • Meditate before bedtime • Drink a glass of warm milk before going to bed The amount we sleep and wake is not a random occurrence. It is regulated by complex chemical transmitters in our brain. During the day, activity causes a chemical called adenosine to build up in our body. When it reaches a critical level, there is an overwhelming desire to sleep. If you have not been sleeping enough, you can build up a “sleep debt” with high levels of adenosine, causing lack of concentration, daytime drowsiness and sudden attacks of sleepiness. These may be socially inappropriate or cause life-threatening accidents. In children, lack of sleep produces paradoxical changes with irritability, aggressiveness and hyperactivity. Our spinning world is governed by light and darkness. The changes in the external environment are reflected in our internal biological clock, a bundle of cells in our brains. These respond to darkness by producing a chemical called melatonin, which produces sleep. These cells get confused when the environment has artificial light. The “blue light” produced by televisions, computer monitors and cell phones is particularly harmful. Infants need 16-18 hours of sleep a day. This drops to 9-10 hours in children and 8-9 hours in teenagers. Adults need 7-9 hours of sleep a day. Adequate sleep is needed to keep the brain chemicals in balance. Long standing sleep deprivation causes these neurotransmitters to go haywire. The production of leptin, responsible for appetite suppression, decreases and its opposing enzyme ghrelin increases. Appetite increases, along with a craving for carbohydrates. Eventually people become obese, develop glucose intolerance and may actually become diabetic. Sleep may be disturbed because of concurrent illnesses or social situations. Urinary tract infection or an enlarged prostrate may require frequent visits to the toilet. Infants may require frequent night feeds. The other people sleeping in the room may snore loudly or grind their teeth. Children may suck their thumb. In the silence of the night, these sounds can appear extremely loud. The common sleep disturbances are: • Insomnia with difficulty in falling and staying asleep with early rising and intermittent bouts of wakefulness. • The restless leg syndrome where there is an irresistible urge to move the legs. This can force people to get to up, shake the leg and walk around. • Sleep apnoea where people stop breathing several times during the night • Narcolepsy with excessive daytime sleepiness and uncontrollable episodes of falling asleep during the day. If you feel you have a sleep disorder, correctable causes must be treated first. Any external factors causing a disturbance, like a noisy partner or electronic equipment in the room, must be tackled. Stimulants like caffeine (coffee, tea and cola), should not be drunk after 2pm. Nicotine (cigarettes, snuff and chewing tobacco) stimulate the brain cells so that sleep is disturbed. Alcohol can “knock you out” fast, but the sleep is deep, disturbed, unnatural and arousal occurs within a few hours. Concurrent medical problems like cardiac failure, renal failure and even bronchial asthma can cause sleep to be uncomfortable and disturbed. The pain in arthritis can cause tossing and turning. Mental changes of Alzheimer’s or early onset dementia can cause lack of restful sleep. Depression makes people wake early. They toss and turn restlessly, unable to sleep again, and have their problems reverberate in their brains. Sleep apnoea sufferers have intermittent episodes in the night when they may snore or stop breathing. They wake up as the carbon dioxide concentration builds up. It may occur because the throat muscles relax too much or because the brain fails to send proper signals to the respiratory centre muscles, ordering them to breathe. It can be fatal. Lack of sleep should be investigated. A diary should be maintained of the sleep-wake patterns. Medical conditions should be investigated and treated. There are “sleep laboratories” which observe, test, diagnose and treat sleep disorders accurately. If sleep eludes you, do not lie in bed tossing and turning. Get up and read a book (television is not a good idea) and try not to become anxious and frustrated. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in Share on emailShare on printShare on facebookShare on twitterMore Sharing Services

breast cancer

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A ticking time bomb

Your Health DR GITA MATHAI

The figures are disturbing. One in 30 urban women and one in 60 rural women in India develop breast cancer by the age of 70. This difference in incidence may be real, or because rural women (out of fear, socioeconomic reasons or ignorance), do not come forward for treatment. Breast cancer develops silently and painlessly. A lump that is “just there” may be ignored. By the time action is taken, it may be really large or have spread to adjacent lymph nodes or disseminated via the blood stream to various other organs like the lungs, liver or bones. There is a great deal of scientific research on breast cancer. This makes it one of the more treatable cancers. The downside is that even though technically the person is cured, the cancer can recur elsewhere — in the same breast, at the scar site or metastasise (spread) to a distant organ even 10-15 years later. Once diagnosed, even if treatment is taken and completed, the disease remains a ticking time bomb. Regular follow up is required. Breast cancer is more likely to develop if: Menstruation began before the age of 12 and menopause after the age of 54 The woman has no more than one child Child birth occured after the age of 30 The woman has a high fat diet BMI (weight divided by height in metre squared) is more than 30. The woman has no aerobic exercise. Some families are more prone to breast cancer. Many of the first-degree relatives (mother, aunts, grandmother, sisters) have breast cancer. These families carry genes and mutations that make them 60-80 per cent more prone to developing the disease. The commonly known genes are the BRCA1 and the BRCA2. The BRCA2 gene is associated with bilateral disease. Men who carry this gene can develop breast cancer. Other less-known genes are also associated with breast cancer. Breast self examination familiarises women with the shape, size and texture of their breasts. It helps them to pick up subtle changes, which may require further investigation. It should be done every month 5-7 days after the periods. Breast cancer can be present in the milk ducts alone. It then causes unilateral discharge of milky fluid or a brown or blood stained discharge. The nipple may get pulled inwards so that its shape is distorted. Bilateral milky discharge is more likely to be non cancerous. It can be due to thyroid deficiency, pituitary disease, fibrocystic changes in the breasts or the side effect of certain motility medications like perinorm or domperidone. The cancer may be in the lobules of the breast. The lump may be clearly felt. The skin overlying it may change in appearance, causing it to have an orange peel (peau de orange) appearance. Once a lump or cancer is suspected, the following may be done: Ultra sound scanning (for screening) Mammogram PET scan MRI Lumpectomy (removal of the tumour) and pathology studies Fine needle aspiration cytology Sentinel node biopsy to see if it has spread. Cancer always starts in a single cell whose multiplication is rapid and uncontrolled. As long as it remains localised, it is called “cancer in situ” or non-invasive cancer. As it grows, it becomes invasive. Some cancers grow fast in the presence of estrogen. They are called ER (estrogen receptor) positive cancer. Aggressive spread of the cancer and a tendency to recurrence occur in women who carry the HER2 gene. If the cancer type is known it is possible to specifically target the estrogen receptors and the HER2 gene. Previously, the entire breast with cancer, the regional lymph nodes and the muscles of the anterior chest wall were removed. Now just the lump is removed, leaving a healthy tissue margin. Sometimes the tumour is shrunk before surgery with radiation or chemotherapy. Carriers of the BRAC2 gene have a four per cent chance of a recurrence in the opposite breast. Some women opt for prophylactic removal of the normal breast. This is an informed choice and not a necessity. Surgery can always be done later if cancer crops up. Personal preventive methods: Breast-feed children to the age of one Maintain ideal body weight Avoid fat-laden food Exercise for an hour a day Perform breast self-examinations regularly to detect changes early Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

balance and coordination http://www.telegraphindia.com/1141006/jsp/knowhow/story_18896719.jsp#.VDPDbmeSya8

Balancing act

Your Health DR GITA MATHAI

In the womb, we float around like fish. Once born, we have to learn to sit, crawl, stand up, walk with one foot always touching the ground and run with both feet off the ground. Later we progress to activities that need even more balance, such as riding a bicycle or playing structured games. These skills are lost in reverse as we age. We acquire balance as our nerves mature. We develop a complex interplay of nervous activity with smooth, rapid connections established between the eyes, the vestibular (balance) apparatus in the ears, muscles, bones, peripheral nerves and brain. Constant use and practice hones these pathways. If the centre of gravity shifts and falls outside the base of support (the feet if we are standing or buttocks if we are sitting), we tilt and fall. After the age of two, children are able to correct this easily, automatically widening their feet and legs. As age advances, adults slowly lose this ability. Loss of balance and falls spike sharply after the age of 65. In addition to balance, we require coordination — the ability to perform smooth, accurate, controlled movements, visualising and gauging the distance and the strength required for the action. The graceful strokes of a tennis player or the movements of a basketball team are evidence of this. One of the commonest causes of loss of balance and coordination in older people is lack of exercise. Disuse makes muscles flabby. They are no longer able to support the body and reaction time is slowed. Weak muscles do not respond rapidly or appropriately. Low levels of calcium, with or without vitamin D3 deficiency, is common in older adults. This not only makes muscles flabby but also sends them into spasms. A sudden cramp can cause loss of balance. Substance abuse, particularly alcohol, disturbs the internal equilibrium. When a person who has imbibed a little loses his balance, he are usually able to correct himself . Once he has drunk too much, he “passes out” and lies wherever and however he has fallen. The same holds true of people who have taken recreational drugs like marijuana. Even excess of coffee has a similar effect! If a person who has taken a sleeping pill is woken up suddenly, he can be disoriented. If he tries to stand up, he can lose his balance and fall, particularly if the room is dark, as the eyes are unable to compensate. This is why many physicians are reluctant to prescribe sleeping pills for older adults. Vitamin B 12 deficiency causes a glove and stocking type of loss of sensation in the hands and feet. As the person cannot accurately gauge or feel the position of his feet, there can be loss of balance. Aerobic exercises such as walking, jogging, running, cycling and swimming is recommended for 40 minutes a day to maintain health. In addition, solving puzzles such as sudoku or learning poetry is recommended to keep neurons alive and active. Additional exercises for balance should be done for 10 minutes. Any movements that are repetitive and involve rapid transition from one hand or leg to another is good for maintaining balance and coordination. FIT AND FINE • Pretend to sit on a chair. Hold the pose for 20 seconds. Repeat twenty times • Lift one leg (hold a chair if necessary) till the hip is flexed to 90 degrees. Hold for a count of 20. Repeat with the other leg. Do 20 repetitions • Get down on hands and knees. Stretch a leg out and the opposite hand. Hold for a count of 20. Repeat with the other leg. Do 20 repetitions • Cycle in the air touching the opposite knee with the elbow. Do 50 repetitions • If there is a ladder, place it flat on the ground. Run or walk through the rungs forwards and backwards 5-6 times • There are several yoga poses that help with balance, like the tree, eagle or warrior pose. It is better to go to a yoga class and learn from an instructor Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in