24th SEptember 2000

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A little TLC for heart under attack

For many people who have a heart attack, it is a life-changing experience. They often feel grateful for having survived -at least a third die before they even manage to get to hospital- and are determined to re-evaluate life in a positive way. Some people find that once they have fully recovered they feel better than they have for years.

But it is also an enormous shock which can force a person to confront their unhealthy habits and address their worst fears, whether that means accepting that it really is time to give up smoking or facing up to the inescapable certainty of the ageing process and man's mortality. It's hardly surprising that as many as one in four people suffer from depression after a heart attack.

Many people live in fear of another attack - and with good reason. About 10% of those people who have a heart attack will have another one within a year of leaving hospital. This risk drops to about 3% every year after that. Proper rehabilitation, which includes making changes to your lifestyle, can reduce these risks and increase your life expectation. The first 48 hours are critical. After this recovery begins. Within a few days the tissues of the heart begin to heal and, if there are no complications, you may be discharged from hospital after 5-7 days. As the weeks pass, the damaged muscle is replaced by scar tissue. This process usually takes 6-12 weeks, during which time you should be gradually increasing your activity.

Many people are terrified of exercising after a heart attack for fear that it will trigger another. But exercise actually helps to speed up your recovery back to normal. A gradual increase in exercise helps the heart to get back into shape and adapt to any scars left behind. It also improves general wellbeing and encourages good quality, regular sleep. It helps test out your heart so that you and your doctor become aware of any residual problems like angina or breathlessness. Always follow expert advice regarding this increase in exercise. Never overdo things. Excessively vigorous exercise can cause another heart attack.

After 6-12 weeks, in uncomplicated cases, you should be effectively back to your normal life. This includes returning to:

Work: exactly when you return depends on the work you do and how serious the heart attack was. Take it in stages and rest when you feel tired. Some very physical jobs may be beyond you at first.

Driving: but avoid long journeys and stressful driving.

Sex: many people worry that sexual activity may be too strenuous for their heart after a heart attack. But research shows these fears are generally unfounded. Like all exercise, take it slowly at first. After a heart attack, drug treatments can reduce the risk of another by as much as 25%, depending on your particular condition. Drugs which may be used include Aspirin and other drugs which reduce the formation of blood clots, lipid lowering drugs, beta blockers which reduce any high blood pressure, "ACE" inhibitors which make the workload of the heart easier and other drugs to treat abnormal rhythms of the heart. Changing your lifestyle can greatly reduce your risk of a further heart attack:

1. Give up smoking. This is the single most effective way of reducing risk (it halves the risk). A heart attack is powerful motivation for stopping - 50% of those who try at this time succeed.

2. Regular exercise.

3. Keep your weight under control and seek medical advice about your diet.

4. Monitor your blood pressure regularly.

5. Learn to deal with anger and stress which can trigger an attack.

Oh no, what do we do ?

One of the inescap-able facts about sex is that it sometimes happens unplanned and without protection. Thousands of pregnancies start this way. Often, the pregnancy is unwanted, and the start of a nightmare dilemma for the woman and her partner. Fortunately, it is possible - if you act quickly after the event - to prevent a pregnancy developing by using what is now called the 'morning after pill'.

This is a drug, which you can get from your doctor or family planning clinic, and which must be taken within 72 hours of unprotected sex. It's also known as the post-coital pill. It's not an ideal solution - the real answer is to avoid the risk in the first place by using a reliable contraceptive, which can also protect against infection, such as a condom, when you have sex. But as a one-off solution to a crisis, it may help prevent the misery of an unwanted pregnancy.

* How does the morning-after pill work?

The morning-after pill consists of a high dose of female hormones - the same hormones found in the normal contraceptive pill. It acts by disturbing the hormonal balance required for a pregnancy to occur.

*Are there side effects?

Nausea and vomiting after taking the pill are a problem - not surprising given the high doses of hormones involved. Other side effects are relatively minor, such as headache. There are a few women who should not use the morning-after pill because of other medical conditions- and your doctor who prescribes the drug should check these out.

*How reliable is it?

Less than one percent of women who take the morning-after pill within 24 hours of unprotected sex will become pregnant. Every 12-hour delay after that, increases the failure rate by 50%. After 72 hours, it becomes unreliable.

*What does it do?

The morning-after pill acts to change the lining of the womb so that if the woman's egg does become fertilized by the man's sperm, it is unable to implant or attach to the womb to start a pregnancy. Unable to "stick", the fertilized egg is then expelled from the womb.

* Where is it available?

In this country, the pill is available with the Sri Lanka Family Planning Association. It can also be obtained from your doctor by prescription, if he is satisfied that the circumstances warrant its use.

That grumbling pain

Ask a question from Dr. Maiya Gunasekera, MBBS Hon (Cey), M.S. FRCS (Eng), FRCS (Ed), FICS Fellow Sri Lanka, Consultant Surgeon/Gastro Enterologist at the Nawaloka Hospital.If you wish to consult him on your personal health through this page, do write in, c/o The Sunday Times, P O Box 1136, Colombo
By Chris Fernando

Q: I am a 30-year-old executive. I have been suffering from abdominal pain recently. I feel nauseous and the pain at that time gets worse on the right lower abdomen.

I have consulted my doctor who tells me that this can be due to appendicitis. This is a bit confusing, since I know of a couple of friends who've had severe pain coupled with vomiting and were operated for appendicitis. After surgery, the surgeon had informed them that their appendix had been infected.

I've had pain on two occasions, which passed away, but then recurs later. Can my condition be due to appendicitis?

Dr. Maiya says: Thank you for your question. The appendix, as you may know, is an elongated blind-ended appendage at the beginning of the large bowel. This site will correlate to the right lower abdomen or the right illiac fassa. It has no known useful function, but can get into trouble if its lumen (opening) gets blocked. Since the appendix is also a part of the bowel, it also produces some secretions, which are extruded into the caecum, which is the beginning of the large bowel, through a small opening.

Now if this opening gets blocked by a piece of hard faecal matter, the appendix will try to push it out to clear the outlet. This will cause pain, which is colicky in nature, and the pain will be around the navel. The pain will come and go and if the appendix is successful in clearing the block, the pain will go off completely.

However most often, the appendix is unable to clear the blockage and secretions get collected inside the appendix. This in turn gets infected and it loses its function and ability to contract. The pain, which earlier would have been colicky and around the navel, would therefore, now get confined to the right lower abdomen. The right lower abdomen will be tender to touch on examination. These are the classic signs and symptoms of acute appendicitis, which needs urgent surgery.

There are certain blood tests, which will show evidence of infection like the white blood cell count and the ultrasound examination, which may also show an inflamed swollen appendix.

An ultrasound examination and the white blood cell count together with the physical examination will confirm a diagnosis of acute appendicitis. Furthermore, ultrasound examination will also throw light on to other pathologies, which can mimic symptoms of acute appendicitis such as a right-sided ovarian cyst or right-sided urinary problems.

On physical examination, if the appendix is inflamed and lies superficially, the patient would jump because of pain. But if the appendix is inflamed and in a deep position hidden by the large or small bowel, the patient will still experience some pain, which will be less tender to touch. However, the patient will have pain if the area is pressed deep so the signs of tenderness to touch will depend on the position of the appendix.

An appendix can vary in size and length from individual to individual. If one has a long appendix, which can get kinked easily, then the chances of one having appendicitis early would be more, but this is not a rule.

I think in your case, it is possible that a faecolith has got into the appendix. The appendix could have pushed it out but if you're getting recurring pain, this could be due to a grumbling appendix with a few faecoliths inside. There may come a time however, that this will get infected and show up as a full-blown appendicitis. But your pain could also be due to Irritable Bowel Syndrome.

Therefore, it is advisable that you do an ultrasound examination and white blood cell count. If the diagnosis of appendicitis is in doubt, I would also advise a colonoscopy from which you could get a good view of the inner lining of the caecum and large bowel.

A CT Scan of the abdomen can also be done to throw more light on the problem. But from your explanation of the problem, it is likely that you have a grumbling appendix. However, the investigations that I have suggested may help you avoid an unnecessary operation.

Kick the craving for a puff

Smoking has for long been considered an addiction but drugs or chemicals being used to treat it is relatively new. This approach is 'Nicotine Replacement Therapy'(NRT). It is still not widely used in Sri Lanka but is gaining popularity in western countries because of its high rates of success in helping smokers quit.

What NRT does is to help take off the craving for a smoke without providing the tars and poisonous gases found in cigarettes. But ideally, NRT should be used as only part of a full programme aimed at helping you to stop smoking. This should include psychological approaches such as counselling, quit-smoking groups, and methods to help you understand the behaviour, which surrounds your habit and how to change this.

Nevertheless, there is no doubt that NRT can increase the chance of giving up forever.

There are several different types of nicotine replacement therapy, including transdermal nicotine patches, nicotine gum, intranasal nicotine spray, and inhaled nicotine. There doesn't seem to be a significant difference in the results with each of these. At present some of these preparations are available in Sri Lanka in the private sector and it is best to ask your doctor about it.

Although results may be similar, the different types of nicotine treatment have different features, which suit different people.

For example, nicotine patches release nicotine slowly, but nicotine nasal spray delivers nicotine more rapidly, so it can help sudden strong urges to smoke.

You will also need to think about doses, and how long the treatment lasts because at present, NRT is costly and is not available in the state sector. But then, even cigarettes are expensive and NRT could be a worthwhile investment in the long run.

Make your heart race faster and beat the stroke

A stroke is when an area of the brain is deprived of its blood supply for 24 hours or more - usually because of a blockage or burst blood vessel - causing vital brain tissue to die. It is essentially the same as what happens in the arteries leading to the heart when someone has a heart attack.

The commonest type of stroke is an 'ischaemic stroke' where a vessel is blocked by a blood clot, which interrupts the brain's blood supply. The other type is a 'haemorrhagic stroke' where a blood vessel in or around the brain ruptures causing bleeding, or a haemorrhage. The build-up of blood presses on the brain damaging its delicate tissue, while other brain cells in the area are starved of blood and damaged.

A 'transient ischaemic attack' often known as a mini-stroke, is when the blood supply to the brain is interrupted for a shorter period of time - anything from a few minutes to 24 hours - followed by complete recovery. In about one in five people it can be a warning sign of a subsequent stroke.

The brain is the most complex organ in the body. It regulates absolutely everything your body does - breathing, moving, sweating, sleeping, waking, feeling, your moods, your thoughts, your speech. To perform all these functions the brain must have a constant supply of blood to deliver oxygen and nutrients to the brain cells. If the blood supply fails, as in a stroke, the brain cells become damaged or die. Unlike other cells in the body, brain cells once they die cannot grow again.

A number of tests may be performed to pinpoint the type of stroke and help the stroke team decide on the most appropriate treatment. They may include blood pressure measurement, blood sampling, x-rays, an electrocardiogram (ECG) to assess the heart's rhythm, an echocardiogram, to look at the heart's structure, and brain scans such as, computed tomography (CT scans) to check the kind of stroke and view the extent of damage.

Drug treatments are designed to treat the effects of stroke, to prevent complications and to help treat risk factors in the hope of preventing a further stroke occurring. There are hundreds of drugs that may be used.

Of people who survive a stroke around half will be left with significant disability. Having said that, the brain is remarkably adaptable and in the months or years after a stroke many cells which have sustained damage recover some of their function. At the same time other areas of the brain take over the functions performed by the cells that have died. The time it takes to recover is extremely variable. However, commonly people have a surge of recovery in the weeks following a stroke followed by a slower recovery over the next year to 18 months or so. The aim of rehabilitation is to encourage and enhance this process.

The process of rehabilitation may include physiotherapy, speech and language therapy, occupational therapy and psychological help and a number of different experts may be involved. Rehabilitation should begin in a specialised stroke unit, in hospital or at home. Starting rehabilitation as early as possible can substantially improve recovery and reduce the effects of the stroke.

Paying attention to what you eat can reduce the risk of having a stroke. Too much salt and saturated fats (found in animal fats like meat, cheese and butter) increases the risk of stroke, while a diet rich in fruit and vegetables, which contain anti-oxidants which help protect the blood vessels, unsaturated fats and fibre can help lower the risk.

Regular physical activity helps improve the condition of the heart, enhances circulation, lowers blood pressure, lowers cholesterol levels and helps keep weight down so helping reduce the risk of stroke. It can also help you feel more energetic and cheerful.

The most important kind of exercise, aerobic exercise - the kind that gets your heart beating faster, makes you sweat and leaves you slightly out of breath - can be achieved quite simply by adjusting your daily routine. Walking to the shops, using the stairs instead of the lift, getting off the bus a stop earlier, and going for a longer brisk walk at weekends can all improve your quality of life in a simple but significant way- by greatly reducing the risk of a stroke.

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