Sleep problems are among the commonest concerns that parents have with their children. About one in four of all children are said to have sleep problems at some stage. Some have difficulty in getting to sleep, others in staying asleep, while others have their sleep interrupted by nightmares or night terrors. All children, like adults, need adequate sleep to replenish energy. Insufficient or interrupted sleep has a deleterious effect on children at any age. Children’s sleep problems also have an impact on the rest of the family and they create an enormous amount of stress for parents, whose own sleep is often interrupted.
There is a great deal of individual variation in sleep patterns and requirements at all ages. What seems sufficient for one child is too little for another. All babies, children and adults go through specific sleep cycles. They move systematically from deep sleep to light sleep to REM (rapid eye movement) sleep. This cycle repeats itself about five times in 8 hours of sleep. Dreaming takes place in REM sleep, which seems to last about 10-20 minutes at a time.
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Having cancer is a very tiring business! I’d be very surprised if you had never experienced this symptom. The cancer itself can sap your energy, especially if it is extensive and/or you have lost some weight. Many complications of cancer cause general weakness and lack of energy — for example, anaemia; lungs, liver or kidneys that don’t work properly; and too much calcium or too little sodium or potassium in the blood. All forms of cancer treatment can be very tiring. Of course, nervous tension and worry about the future can make you feel very tired and disinterested in any of your normal activities, even ones that you are physically well enough for.
It is worth checking for those factors that can be treated amongst the ones I have mentioned above if you feel particularly tired and lacking in energy. For example, anaemia can be righted with a blood transfusion. The mineral disturbances mentioned can all be corrected if they are found. Perhaps your anti-cancer treatment can be modified—ask about cutting down doses for example. You should also consider stopping your anti-cancer treatment altogether. Weigh the costs you are now experiencing against the likely benefits — your decision may not be the same as when you first agreed to have the treatment. Then you were working on what you were told was likely, now you can reconsider in the light of what is actually happening to you.
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These injuries are due to violence occurring around the joints. The joint is disrupted and the bones moved from their normal position.
The earlier medical attention is sought, the easier it is to reduce the dislocation. Once the joint has been displaced for some time, rather strong muscular spasm is present, and it may be necessary to anaesthetise the patient to reduce the dislocation.
Simple dislocation of the finger joints can often be replaced by firm pulling of the end of the finger, and holding the wrist with the other hand.
It may be easier to do so immediately after the finger has been dislocated, and many sportsmen are quite adept at fixing their colleagues’ dislocated fingers.
The shoulder joint is a shallow “ball-and-socket” joint and is often subject to dislocation. Only a doctor should attempt its reduction because of damage to nerves and arteries through careless handling.
Some people develop recurrent dislocation of the shoulder, which may “come out” with only a very trivial injury. They become adept at replacing it.
An operation is available to correct recurrent dislocation of the shoulder.
A great deal of force is required to dislocate the knee or the hip, and these injuries are often seen in motor vehicle accidents. They are only to be handled by the expert.
First aid is to immobilise the injured part, relieving pain and treating shock.
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Sometimes, when the gallbladder is not functioning properly, it fails to concentrate the dye and poor films are the result. However, a non-functioning gallbladder on a cholecystogram is indicative of disease. Sometimes the dye is given by injection.
Ultrasound scanning may also be used in detecting gallstones.
Once the diagnosis is made, treatment will be recommended. Of course, this will depend on the symptoms from which the patient is suffering and whether any complications are present.
Large gallstones discovered accidentally, and which are causing no symptoms, are probably best left alone. Multiple small stones are better removed.
This is because they are prone to move and enter the common bile duct, obstructing it. Operation is then a matter of urgency and is more difficult and requires a longer convalesence.
Unfortunately, operation remains the main way of dealing with this problem. It usually only involves a stay of five to seven days in hospital.
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Because most doctors are male, many may not fully appreciate how severe the worry can be to the woman with an excess of body or facial hair. Not every woman with the problem needs to be fully investigated by special tests. A full history and examination usually including a pelvic examination to assess the reproductive organs, should exclude most of the serious disorders. It may be necessary occasionally to carry out hormonal assays by blood tests.
Unfortunately, there is no simple or effective treatment. If there is a definite cause for increased androgen activity it should be treated.
Drugs are sometimes used to counteract the androgen effect. Cortisone in small doses may be effective and the Pill is often used for the same reason. Sometimes, the two are combined. ”
In those who are both obese and hairy, reducing weight may restore the body’s hormonal balance and solve both problems.
In most cases, bleaching the offending hairs so they become less noticeable is acceptable only to a minority. Yet this can be combined with other treatment so that these methods need be used less frequently.
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Say your doctor tells you that one in twenty (five per cent) of patients with your particular type and stage of cancer are cured with a particular treatment. The median survival is twelve months. The five year survival is one in twenty (five per cent). What does this mean for you? It means that if you have this treatment, there is a fifty-fifty chance that you will live less than twelve months. There is only a one in twenty chance that you will live five years but if you do, you will know you are almost certainly completely cured. Imagine for the same situation, if your doctor simply said ‘You could be completely cured and live as long as you would have if you had never had the cancer’. This is true but doesn’t really give a complete picture. A patient told only this would be much more likely to agree to a twelve month course of intensive chemotherapy than a patient who knew that there was a fifty per cent chance of dying before even completing the treatment. So do make sure that you get more detailed information than what is possible but unlikely. This is the part the doctor is most likely to tell you, but on its own and without percentage figures it can be very misleading.
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Metabolism. Our genetic make-up also underlies our metabolism, (basically how many kilojoules we burn per minute). Bodies, like cars, differ in this regard. A V-8 consumes more fuel to run than a small 4-cylinder car. A bigger body, generally, requires more kilojoules than a smaller one. Everybody has a resting metabolic rate. This is a measure of the amount of kilojoules our bodies use when we are at rest. When a car is stationary, the engine idles—using just enough fuel to keep the motor running. When we are asleep, our engine keeps running (for example, our heart keeps beating) and we use a minimum number of kilojoules. This is our resting metabolic rate. Our resting metabolic rate is the amount of kilojoules we burn without any exercise. When we start exercising, or even just moving around, the number of kilojoules, or the amount of fuel we use, increases. However, the largest amount (around 70 per cent) of the kilojoules used in a 24-hour period are those used to maintain our basic body functioning. Since our resting metabolic rate is where most of the kilojoules we eat are used, it is a significant determinant of our body weight. The lower your resting energy expenditure the greater your risk of gaining weight and vice versa. We all know someone who appears to ‘eat like a horse’ but is positively thin! Almost in awe we comment on their ‘fast metabolism’, and we may not be far off the mark!
All this isn’t to say that if your parents were overweight that you should resign yourself to being overweight. But it may help you understand why you have to watch your weight while other people seemingly don’t have to watch theirs.
So, if you were born with a tendency to be overweight, why does it matter what you eat? The answer is that foods (or more correctly, nutrients) are not equal in their effect on body weight. In particular the way the body responds to dietary fat makes matters worse. If you are overweight it is likely that the amount of fat you burn is small, relative to the amount of fat you store. Consequently, the more fat you eat, the more fat you store. Although this may sound logical, the ‘eat-more, store-more’ mechanism does not exist for all nutrients.
Amongst all four major sources of kilojoules in food, (protein, fat, carbohydrate and alcohol), fat is unique. When we increase our intake of protein, alcohol or carbohydrate the body’s response is to burn more of that particular energy source. Sensibly, the body matches the supply of fuel with the type of fuel burned. One of the fundamental differences between fat and carbohydrate is that fat tends to be stored whereas carbohydrate has a tendency to be burned. It is worth noting at this point that if your carbohydrate intake is low, it may reduce the amount of kilojoules you burn each day by 5 to 10 per cent While you may not have been born owning the best set of genes, you can still influence your weight by the lifestyle choices you make. The message is simply this: if you believe that you are at risk of being overweight, you should think seriously about minimising fat and eating more carbohydrate.
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Fat has a protective role for survival. Studies carried out with native African women show that they can lose up to 50 per cent of their body mass in the hungry season and then regain this in good times, without any major long term ill-effects. However, in doing so, the body shifts to a lower level of body mass including FFM and this reduces the resting and non-resting metabolic rates.
One extrapolation of the effects of adaptations is that the metabolism might become ‘fixed’ in its energy/fat sparing mode from repeated weight loss and gain cycles. This is popularly expressed as an increasing difficulty in losing weight and increasing ease of regaining weight with each cycle. Usually these series of weight cycles take place over a period of several decades and the effects of increasing age on weight loss and gain may well explain most of this phenomenon. There is no evidence that the metabolism gets permanently stuck in an energy/fat sparing mode, but then again getting evidence to prove or disprove the hypothesis is very difficult. The theory, however, has been popularised by Cannon and Einzig in their best selling book Dieting Makes You Fat? and is also expressed in several recent ‘anti-dieting’ approaches. It is thus important to understand the extent of adaptation that occurs and possible ways of counteracting this.
Prentice and his group have studied energy sparing adaptations from a range of different energy level diets and concluded that the decrease in metabolic rate resulting from dieting, generally varies between 15-25 per cent. This is obviously large enough to slow down any ongoing fat loss. The decrease in metabolic rate is also generally proportionately greater than the decrease in body weight (at least in the early stages by about 3:1).
The changes in metabolic rate are probably mediated by a reduction in circulating thyroid hormone tri-iodothyrine (T3) and reductions in sympathetic nervous system activity. Thyroid hormone has been used to try to counteract the decline in RMR, but it has had so many negative effects on reducing muscle mass and causing medical problems that it is now not used for this purpose.
Prentice’s group have carried out a theoretical analysis on the long term effects on body weight of a number of different energy level diets. It is presumed that adaptive responses will be more vigorous if the energy deficit is greater and weight loss is faster, although there is not a lot of evidence to back this up. The response, however, does seem to be proportionally greater in leaner people and this was observed by Ancel Keys (whose quote is at the beginning of this chapter) who studied the metabolic responses to semi-starvation in lean men who were staging a hunger strike in the 1940s. He noted, as did Leibel, that one of the most marked adaptations to a significant negative energy balance is lethargy and a reduction in physical activity including spontaneous activity.
Dieting can elicit energy sparing adaptations almost immediately it is begun. The changes that occur over time to RMR during dieting and re-feeding (i.e. gradually increasing the food intake over time). There is an immediate decrease in RMR of around 5 per cent on day 1 of a diet. This continues at a decreasing rate over time to around 15-25 per cent. On re-feeding, as can be seen from the shaded bar on the right of figure 14.5, there is again an immediate jump in metabolic rate of around 5 per cent. This helps to explain the positive benefits of re-feeding, particularly in cases where patients have been on very low calorie diets for long periods. Gradual re-feeding can actually help them to lose fat, at least up to a certain point (which is probably around 1200-1500kcal per day) due to this gradual reduction of energy sparing and its effects on metabolism.
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Ignoring protein and alcohol, fat is carried in the bloodstream in the form of free fatty acids (FFAs) which have been broken down from triglycerides (TGs) from food and fat stores. The other main source of energy is sugar (glucose). Glucose is used up readily in muscle tissue as energy when it is available in significant amounts, such as after a meal (hence the thick arrow from glucose to the muscle). Otherwise, the muscle uses FFAs as its main source of energy (such as after overnight fasting, in which case there would be a thick arrow from FFAs to the muscle). FFAs are efficiently stored as triglycerides in the fat cell. The obligatory biochemical cost of storage of fat as body fat is about 3 per cent of the energy available in the fat. The cost of converting glucose to fat on the other hand (de novo lipogenesis) is around 25 per cent of the available energy in the carbohydrate, which helps to explain why de novo lipogenesis is now not thought to occur significantly in humans under normal physiological conditions i.e. non-forced feeding of carbohydrate.
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Tetanus is a disease too terrible to think about. It can affect anybody, and this includes the newborn. In fact, of the million or more cases of tetanus deaths that are reputed to occur world-wide each year, about half are of infants under the age of 12 months. Inadequate hygiene and lack of specific protection are the main reasons.
The disease is produced by an organism called Clostridium tetani. This organism can produce spores which are very resistant and can live for a long period of time. They are a normal inhabitant of the bowel, and for this reason are very common in manure. That’s why persons who enjoy gardening are at special risk. Once it starts to multiply, the germ produces an extremely powerful toxin which may be rapidly fatal. Many cases occur from simple puncture wounds in which germs have been inserted. Often the wound is so small that the person is unaware of it happening. Babies in the Third World are at special risk, for their umbilical cord is a wonderful spot for the germs to dwell and multiply.
The incubation period varies from five days to five weeks. Onset of symptoms may be heralded by crampy pains in the muscles, commonly of the back or abdomen. The patient shows restlessness, irritability and difficulty in swallowing. There may be early convulsions. Gradually, the muscle stiffness and tension increases. The muscles of the jaw often are affected early. They contract, giving the false impression the patient is grinning. As time passes, swallowing becomes more and more difficult, wild tetanic spasms of the muscles occur, with the head and back retracting, and intense pain is felt. Fists and jaws clench.
The course of the disease is terrible and the agony experienced is major and terrifying. Parents should know of these symptoms in detail to understand the urgent need to prevent this awful disease from developing in their own offspring.
Tetanus is a totally preventable disease. In fact, the protection afforded by adequate immunization is remarkable. This is usually started when the baby is two months old. (Refer to the childhood immunization schedule given earlier in this chapter.) The procedure is a very simple one, but the beneficial effects are enormous.
It can totally prevent tetanus, and is probably the most amazing and complete cover against disaster that is currently available in this country. It is wise to continue with regular updating booster shots, ideally throughout life. Therefore following the initial course started at two months, boosters are offered at 18 months, then pre-school and ideally each 5-10 years thenceforth for the rest of a person’s life. If a dirty wound occurs meanwhile, most doctors suggest an immediate booster at that moment also, just to be doubly sure.
There are about twenty cases of tetanus annually in Australia. This is fairly high when it is considered that in Great Britain, a country with a population four times that of Australia, they also have about twenty cases annually.
Treatment
Treatment of tetanus, of course, is basically to prevent it by sensible immunization. After any wound that is potentially dirty—and this may include simple gardening injuries—a check with the doctor is advised to ascertain whether a booster shot is necessary, or other protective given, irrespective of the age of the child.
Tetanus itself requires particularly skilful treatment, ideally in the intensive care ward of a major hospital which has access to full nursing and medical facilities. At the first sign of any of the symptoms after an accident, irrespective of how minor, medical attention by the doctor is strongly advised.
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