POSTHERPETIC NEURALGIA (SHINGLES)

What is postherpetic neuralgia?

Postherpetic neuralgia is a nerve pain (neuralgia) that persists after a shingles rash has cleared.

Shingles (herpes zoster) is an outbreak of rash or blisters on the skin that is caused by the same virus that causes chicken pox - the varicella-zoster virus.

The first sign of shingles is often burning or tingling pain, or sometimes numbness, in or under the skin. You may also feel ill with fever, chills, headache, or upset stomach.

After several days, a rash of small fluid-filled blisters, reminiscent of chickenpox, appears on reddened skin.

The pain associated with shingles can be intense and is often described as "unrelenting."

Anyone who has had chickenpox is at risk for shingles. Scientists think that in the original battle with varicella-zoster, some of the virus particles leave the skin blisters and move into the nervous system. When the varicella-zoster virus reactivates, the virus moves back down the long nerve fibers that extend from the sensory cell bodies to the skin and cause the characteristic blisters of shingles .

Is there any treatment?

The severity and duration of an attack of shingles can be significantly reduced by immediate treatment with antiviral drugs, which include acyclovir, valcyclovir, or famcyclovir.

Antiviral drugs may also help stave off the painful after-effects of shingles known as postherpetic neuralgia.

Other treatments for postherpetic neuralgia include steroids, antidepressants, anticonvulsants, and topical agents.

What is the prognosis?

For most people, the lesions heal, the pain subsides within 3 to 5 weeks, and the blisters leave no scars.

However, shingles is a serious threat in immunosuppressed individuals � for example, those with HIV infection or who are receiving cancer treatments that can weaken their immune systems. People who receive organ transplants are also vulnerable to shingles because they are given drugs that suppress the immune system.

PNEUMOCOCCAL INFECTION AND VACCINATION

Streptococcus pneumoniae, also known as pneumococcus, is a bacterium that is often found in the noses and throats of healthy persons and is spread person-to-person through close contact. Pneumococcus is a common cause of mild illnesses, such as sinus and ear infections, but also causes life-threatening infections such as pneumonia, meningitis, and infections of the bloodstream. Many strains are resistant to antibiotics.

Occurrence

Risk for pneumococcal disease is highest in young children, the elderly, and persons of any age who have chronic medical conditions such as heart disease, lung disease, or diabetes, or conditions that suppress the immune system, such as HIV. Smokers and those in close contact with small children are also at higher risk. Pneumococcal disease is more common in winter months and when respiratory viruses such as influenza are circulating. Outbreaks of pneumococcal disease are not common but can occur in child care centers, nursing homes, or other institutions. In the United States, most deaths from pneumococcal disease occur in older adults, although in developing countries many children die of pneumococcal pneumonia.

Risk to Travellers

Pneumococcal disease occurs worldwide. Crowded settings or situations with close, prolonged contact with young children may increase the risk of contracting pneumococcal disease while travelling.

Clinical Presentation

Fever and malaise are typical symptoms for all forms of pneumococcal disease and may be the only symptoms in young children with blood infections.

Patients with pneumonia usually have cough, often with purulent or blood-tinged sputum, and may have shaking chills, shortness of breath, or pleuritic chest pain. Fever and sputum production may be absent in elderly persons with pneumococcal pneumonia.

Patients with pneumococcal meningitis have headache, photophobia, stiff or painful neck, vomiting, lethargy, or decreased consciousness.

Persons with pneumococcal ear infections typically have pain in the infected ear and can have purulent drainage (pus) following perforation of the ear drum.

Sinus infections cause pain over the sinuses or in the teeth.

Prevention Vaccines

Two vaccines are available to prevent pneumococcal disease; the pneumococcal conjugate vaccine (PCV) (Prevnar, Wyeth Vaccines) and the pneumococcal polysaccharide vaccine (PPV) (Pneumovax, Merck). Both vaccines provide protection by inducing antibodies to specific types of pneumococcal capsule; 90 different types of pneumococcal capsule have been identified. The conjugate vaccine protects against the 7 serotypes most common in young children in the United States; the polysaccharide vaccine includes 23 types. Both vaccines are effective at preventing invasive disease; the severe form of pneumococcal disease in which the organism is found in blood, spinal fluid, or other typically sterile bodily fluids. The conjugate vaccine, licensed for use in young children, also prevents some pneumonia and ear infections.

Pneumococcal conjugate vaccine

The pneumococcal conjugate vaccine is part of the routine infant immunisation schedule. Health-care visits to receive travel-related vaccines provide a good opportunity to make sure that all routine vaccines are up to date. The pneumococcal conjugate vaccine is recommended for all children <2>

• Sickle cell haemoglobinopathies,
• functional or anatomical asplenia,
• received or will receive a cochlear implant,
• HIV infection,
• chronic disease, including chronic cardiac and pulmonary disease (excluding asthma), diabetes mellitus, or cerebrospinal fluid leak; and
• immunocompromising conditions, including a) haematologic or other disseminated malignancies; b) chronic renal failure or nephrotic syndrome; c) ongoing immunosuppressive therapy; and d) solid organ transplant.

Pneumococcal conjugate vaccine also should be considered for healthy children 2-4 years of age, especially those 24-35 months old, those attending group child care, and those of African-American, Alaskan Native or Native American descent.

Pneumococcal polysaccharide vaccine

The pneumococcal polysaccharide vaccine is part of the routine adult immunisation schedule, but many adults who should have received the vaccine have not. In 2003, only 62% of adults 65 years of age had received the vaccine.

Pneumococcal polysaccharide vaccine (Pneumovax) is recommended for all adults 65 years of age and for persons 2-64 years of age with certain chronic illnesses or immunocompromising conditions, including:

• chronic cardiovascular disease (e.g., congestive heart failure or cardiomyopathies)
• chronic pulmonary disease (e.g., chronic obstructive pulmonary disease or emphysema, but not asthma)
• diabetes mellitus
• alcoholism
• chronic liver disease (cirrhosis)
• cerebrospinal fluid leaks
• functional or anatomic asplenia
• cochlear implant (or those planning to receive a cochlear implant)
• HIV infection
• multiple myeloma
• immunocompromising conditions, including a) haematologic or other generalised malignancies; b) chronic renal failure or nephrotic syndrome; c) ongoing immunosuppressive therapy; and d) bone marrow or solid organ transplant.

Recommended regimens for use of pneumococcal conjugate vaccine in children <5>

Age at examination (months)		Vaccination history	Recommended regimen1
2-6		0 doses	3 doses 2 months apart, 4th dose at age 12-15 months
		1 dose	2 doses 2 months apart, 4th dose at age 12-15 months
		2 doses	1 dose 2 months after the most recent dose, 4th dose at age 12-15 months
7-11		0 doses	2 doses 2 months apart, 3rd dose at 12-15 months
		1 or 2 doses before age 7 months	1 dose at 7-11 months, with another dose at 12-15 months (2 months later)
12-23		0 doses	2 doses 2 months apart
		1 dose before age 12 months	2 doses 2 months apart
		1 dose at 12 months	1 dose 2 months after the most recent dose
		2 or 3 doses before age 12 months	1 dose 2 months after the most recent dose
24-59	Healthy children	Any incomplete schedule	Consider 1 dose 2 months after the most recent dose2
	High risk	Any incomplete schedule of <3>	1 dose 2 months after the most recent dose and another dose 2 months later
		Any incomplete schedule of 3 doses	1 dose 2 months after the most recent dose

1For children vaccinated at <1 src="http://www.medic8.com/images/gte.gif" id="spc-gte" alt="greater than or equal to" align="bottom" width="14" height="11">12 months should be at least 8 weeks apart.
2Providers should consider administering a single dose to unvaccinated, healthy children 24-59 months old, with priority to children 24-35 months old, children who attend group day care centers, children of African-American descent, and children of Alaskan Native or Native American descent not otherwise identified as high risk.

The polysaccharide vaccine should also be given to those 2-64 years of age who are living in settings in which the risk for invasive pneumococcal disease or its complications is increased, such as certain Native American communities (e.g., Alaskan Natives and certain American Indian populations) and residents of nursing homes and other long-term care facilities.

A single dose of pneumococcal polysaccharide vaccine should be given at age 65 years or at the time a high-risk condition is recognised. Children 2-4 years of age with indications for pneumococcal polysaccharide vaccine should receive polysaccharide vaccine at least 2 months after receiving doses of conjugate vaccine. Persons with an indication for polysaccharide vaccine but with unknown vaccination history should receive one dose. A second dose of vaccine should be used for the following groups:

• persons 65 years of age who received the vaccine at least 5 years before and were <65>
• persons with sickle cell disease, asplenia, renal disease, haematologic or generalised malignancy, or other immunocompromising condition.

For children <10 src="http://www.medic8.com/images/gte.gif" id="spc-gte" alt="greater than or equal to" align="bottom" width="14" height="11">3 years after the first dose; for older persons, revaccination may be given after 5 years. Because of limited data on the safety of multiple doses and on the duration of protection provided by polysaccharide vaccine, recommendations are for a single revaccination 3-5 years after the initial dose. These recommendations have been misinterpreted as suggesting revaccination every 5 years.

Safety/Side Effects

Mild local reactions such as redness, swelling, or tenderness occur in 10%-23% of infants after receipt of conjugate vaccine. Larger areas of redness or swelling or limitations in arm movement may occur in 1%-9%. For pneumococcal polysaccharide vaccine, mild, local side effects occur in approximately half of vaccine recipients and are more common after revaccination. Local reactions usually resolve by 48 hours after vaccination. More severe local reactions are rare. After conjugate vaccine, low-grade fever can occur in up to 24% of children and fever >102.2�F may occur in up to 2.5%. Systemic symptoms, including myalgias and fever, are rare after polysaccharide vaccine.

Precautions and contraindications

Conjugate vaccine is contraindicated for children known to have a hypersensitivity to any component of the vaccine. Health-care providers may delay vaccination of children with moderate or severe illness until the child has recovered, although minor illnesses, such as mild upper-respiratory tract infection with or without low-grade fever, are not contraindications. Revaccination with pneumococcal polysaccharide vaccine is contraindicated for persons who had a severe reaction (e.g., anaphylactic reaction or localized arthus-type reaction) to the initial dose. Data are limited on the safety of pneumococcal polysaccharide vaccine during the first trimester of pregnancy.

Additional Preventive Measures

Persons who smoke cigarettes can reduce their risk of pneumococcal disease by stopping smoking. In addition, improving control of chronic conditions that are predisposing factors for pneumococcal disease, such as diabetes and HIV, may reduce risk. Chemoprophylaxis is not routinely recommended. Daily penicillin prophylaxis for children with sickle-cell haemoglobinopathy is recommended beginning before 4 months of age. How long to continue prophylaxis is somewhat controversial. However, children with sickle-cell anaemia who had taken prophylactic penicillin for prolonged intervals but who had not had a severe pneumococcal infection or a splenectomy have stopped prophylactic penicillin therapy at 5 years of age without increased incidence of pneumococcal bacteremia or meningitis. Penicillin prophylaxis is also used for asplenic persons.

Treatment

Pneumococcal disease of all types is usually treated with antibiotics. Mild forms such as uncomplicated ear or sinus infections in healthy persons may resolve without treatment. More serious forms of pneumococcal disease, such as bloodstream infections and pneumonia, require antibiotics and often require hospitalization and intravenous antiobiotics. Pneumococcal meningitis always requires hospitalization and intravenous antibiotics. Because pneumococcal disease is endemic worldwide, care from a physician specializing in travel or tropical medicine is not required.

JOINT REPLACEMENT SURGERY

Joint replacement is one of the most common and successful operations in modern orthopaedic surgery. It consists of replacing painful, arthritic, worn or diseased parts of the joint with artificial surfaces shaped in such a way as to allow joint movement.

Arthroplasty is a common but loose term for joint replacement. Other types of surgery are also arthroplasties. Other common and valid synonyms are total joint replacement, total joint arthroplasty, joint resurfacing and artificial joint surgery.

Technique

Joint replacement is major surgery. The joint must be exposed and dislocated. The joint surface and some bone tissue is then removed from the bone ends and the prosthetic components implanted. They may be fixed by an interference fit with the expectation of bone-ingrowth or using PMMA "cement" as a grout to hold the metal components into the bone. The dislocation of the joint is reduced and the ligaments and muscles over the joint are repaired where possible.

Variations

There are many variations in the exact shape and design of the components and the technique and instruments needed to place them correctly. Although these design innovations are all driven by the impetus to improve results, most of the benefits are unproven. The results are already so good that very large, powerful studies are needed to demonstrate improvement from 95% success to anything better than that.

The main variations in technique are cemented vs cementless fixation; resurfacing or more radical removal of bone; and minimally invasive technique where the exposure is more limited.

Indications

Joint Replacement surgery is indicated when the symptoms, usually pain and loss of function, are disabling. As the risks of surgery are significant, the patient must understand them and prefer to take those risks rather than continue with the symptoms.

Contra-indications

Purulent discharge (infection) in the operative area is considered an absolute contra-indication because of the disastrous consequences of post-operative deep infection. Infection anywhere in the patient is a strong but relative contra-indication.

Poor health is a relative contra-indication as the patient must be strong enough to withstand the stresses of major surgery. Some feel that persistent immobility due to pain is a more serious threat to health even in patients with severe heart and lung disease.

Pre-operative work-up

Because of the major surgery a complete pre-anaesthetic work-up is required. In elderly patients this usually would include ECG, Chest Xray, urine tests, haematology and biochemistry blood tests. Cross match of blood is routine also as a high percentage of patients receive a blood transfusion. Pre-operative planning requires accurate Xrays of the affected joint. The implant design is selected and the size matched to the xray images (a process known as templating).

Post-operative rehabilitation

Early mobilisation of the patient is thought to be the key to reducing the chances of complications such as venous thromboembolism and Pneumonia. Modern practice is to mobilize patients as soon as possible and ambulate with walking aids when tolerated. Depending on the joint involved and the pre-op status of the patient the time of hospitalization varies from 1 day to 2 weeks with the average being 4-7 days in most regions.
Physiotherapy is used extensively to help patients recover function after joint replacement surgery. A graded exercise programme is needed. Initially the patients' muscles have not healed after the surgery; exercises for range of motion of the joints and ambulation should not be strenuous. Later when the muscle is healed the aim of exercise expands to include strengthening and recovery of function.

Timecourse of recovery

A few days hospitalization followed by several weeks of protected function, healing and rehabilitation. This may then be followed by several months of slow improvement in strength and endurance.

Risks and complications:

Medical risks

The stress of the operation may result in medical problems of varying incidence and severity.

• Heart Attack
• Stroke
• Venous Thromboembolism
• Pneumonia
• Increased confusion
• Urinary Tract Infection (UTI)

Intra-operative risks

• Mal-position of the components
o Shortening
o Instability/dislocation
o Loss of range of motion

• Fracture of the adjacent bone
• Nerve damage
• Damage to blood vessels

Immediate risks

• Infection
o Superficial
o Deep

• Dislocation

Medium-term risks

• Dislocation
• Persistent pain
• Loss of range of motion
• Weakness
• Indolent infection

Long-term risks

• Loosening of the components: the bond between the bone and the components or the cement may breakdown or fatigue. As a result the component moves inside the bone causing pain. Fragments of wear debris may cause an inflammatory reaction with bone absorption which can cause loosening. This phenomenon is known as osteolysis.
• Wear of the bearing surfaces: polyethylene is thought to wear in weight bearing joints such as the hip at a rate of 0.3mm per year. This may be a problem in itself since the bearing surfaces are often less than 10 mm thick and may deform as they get thinner. It is also a problem because the wear debris may cause problems.

HEART BYPASS SURGERY

What Is Coronary Artery Bypass Grafting?

Coronary artery bypass grafting (CABG) is a type of surgery called revascularisation, used to improve blood flow to the heart in people with severe coronary artery disease (CAD).

CAD occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become blocked due to the buildup of a material called plaque on the inside of the blood vessels. If the blockage is severe, chest pain (also called angina), shortness of breath, and, in some cases, heart attack can occur.

CABG is one treatment for CAD. During CABG, a healthy artery or vein from another part of the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, it goes around) the blocked portion of the coronary artery. This new passage routes oxygen-rich blood around the blockage to the heart muscle. As many as four major blocked coronary arteries can be bypassed during one surgery.

Overview

CABG is the most common type of open-heart surgery in the United States, with more than 500,000 surgeries performed each year. Doctors called cardiothoracic surgeons perform this surgery.

CABG isn’t used for everyone with CAD. Many people with CAD can be treated by other means, such as lifestyle changes, medicines, and another revascularization procedure called angioplasty.

CABG may be an option if you have severe blockages in the large coronary arteries that supply a major part of the heart muscle with blood—especially if the heart’s pumping action has already been weakened.

CABG may also be an option if you have blockages in the heart that can’t be treated with angioplasty. In these situations, CABG is considered more effective than other types of treatment.

If you’re a candidate for CABG, the goals of having the surgery are to:

• Improve your quality of life and decrease angina and other symptoms of CAD
• Resume a more active lifestyle
• Improve the pumping action of the heart if it has been damaged by a heart attack
• Lower the chances of a heart attack (in some patients, such as those with diabetes)
• Improve your chance of survival

Repeat surgery may be needed if grafted arteries or veins become blocked, or if new blockages develop in arteries that weren’t blocked before. Taking medicines as prescribed and making lifestyle changes that your doctor recommends can lower the chance of a graft becoming blocked.

In people who are candidates for the surgery, the results are usually excellent, with 85 percent of people having significantly reduced symptoms, less risk for future heart attacks, and a decreased chance of dying within 10 years following the surgery.

Types of Coronary Artery Bypass Grafting Traditional Coronary Artery Bypass Grafting

This is the most common type of coronary artery bypass grafting (CABG). It’s used when at least one major artery needs to be bypassed. During the surgery, the chest bone is opened to access the heart. Medicines are given to stop the heart, and a heart-lung machine is used to keep blood and oxygen moving throughout the body during surgery. This allows the surgeon to operate on a still heart. After surgery, the heart is restarted using mild electric shocks.

Off-Pump Coronary Artery Bypass Grafting

This type of CABG is similar to traditional CABG in that the chest bone is opened to access the heart. However, the heart isn’t stopped, and a heart-lung machine isn’t used. Off-pump CABG is sometimes called beating heart bypass grafting. This type of surgery may reduce complications that can occur when a heart-lung machine is used, and it may speed up recovery time after surgery.

Minimally Invasive Direct Coronary Artery Bypass Grafting

This surgery is similar to off-pump, but instead of a large incision to open the chest bone, several small incisions are made on the left side of the chest between the ribs. This type of surgery is used mainly for bypassing the vessels in front of the heart. It’s a fairly new procedure, which is performed less often than the other types. This type of surgery is not for everybody, especially if more than one or two coronary arteries need to be bypassed.

Other Names for Coronary Artery Bypass Grafting

• Bypass surgery
• Coronary artery bypass surgery
• Heart bypass surgery

Who Needs Coronary Artery Bypass Grafting?

Coronary artery bypass grafting (CABG) is only used to treat people who have severe coronary artery disease (CAD) that could lead to a heart attack.

Your doctor may recommend CABG if other treatments, such as lifestyle changes or medicines, haven’t worked. He or she also may recommend CABG if you have severe blockages in the large coronary arteries that supply a major part of the heart muscle with blood—especially if your heart’s pumping action has already been weakened.

CABG also may be a treatment option if you have blockages in the heart that can’t be treated with angioplasty.

Your doctor will determine if you’re a candidate for CABG based on a number of factors. These include the presence and severity of CAD symptoms, the severity and location of blockages in your coronary arteries, your response to other treatments, your quality of life, and any other medical problems you may have.

In some cases, CABG may be performed on an emergency basis, such as pending or during a heart attack.

Physical Exam and Diagnostic Tests

To determine if you’re a candidate for CABG, your doctor will do a physical exam that involves checking your cardiovascular system, focusing on heart, lungs, and pulse. Your doctor also will ask you about any symptoms you have, such as chest pain or shortness of breath, and how long, how often, and how severe they are.

Medical tests will be done to find out which arteries are clogged, how much they’re clogged, and whether there’s any heart damage. Tests may include:

• ECG (electrocardiogram). An ECG is a simple test that detects and records the electrical activity of the heart. This test is used to help detect and locate the source of heart problems. An ECG shows how fast the heart is beating, whether the heart’s rhythm is steady or irregular, where in the heart the electrical activity starts, and whether the electrical activity is traveling through the heart in a normal way.
• Stress test. Some heart problems are easier to diagnose when your heart is working harder and beating faster than when it’s at rest. During stress testing, you exercise (or are given medicine if you’re unable to exercise) to make your heart work harder and beat faster while heart tests are performed.

During exercise stress testing, your blood pressure and ECG readings are monitored while you walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, also can be done at the same time. These would be ordered if your doctor needs more detailed information on blood flow and the heart’s pumping action than the exercise stress test can provide.

If you are unable to exercise, a medicine can be injected through an intravenous line (IV) into your bloodstream to make your heart work harder and beat faster, as if you are exercising on a treadmill or bicycle. Nuclear heart scanning or echocardiography is then usually done.

During nuclear heart scanning, radioactive tracer is injected into your bloodstream, and a special camera shows the flow of blood through your heart and arteries. Echocardiography uses sound waves to show blood flow through the chambers and valves of your heart and to show how well your heart pumps.

Your doctor also may order two newer tests along with stress testing if more information is needed about how well your heart works. These new tests are magnetic resonance imaging (MRI) and positron emission tomography (PET) scanning of the heart. MRI shows detailed images of the structures and beating of your heart, which may help your doctor better assess if parts of your heart are weak or damaged. PET scanning shows the level of metabolic activity in different areas of your heart. This can help your doctor determine if enough blood is flowing to the areas of your heart. A PET scan can show decreased blood flow caused by disease or damaged muscles that may not be detected by other scanning methods.
• Echocardiogram. This test uses sound waves to create a moving picture of your heart. Echocardiogram provides information about the size and shape of your heart and how well your heart chambers and valves are functioning. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that are not contracting normally, and previous injury to the heart muscle caused by poor blood flow.

There are several different types of echocardiograms, including a stress echocardiogram. During this test, an echocardiogram is done both before and after your heart is stressed either by having you exercise or by injecting a medicine into your bloodstream that makes your heart beat faster and work harder. A stress echocardiogram is usually done to find out if you have decreased pumping action of your heart (CAD).
• Angiography. Angiography uses a special dye injected into the bloodstream to outline the insides of arteries on x-ray pictures. An angiogram shows the location and severity of blockages in blood vessels.

Other Considerations

When deciding if you’re a candidate for CABG, you doctor will also consider your:

• History and past treatment of heart disease, including surgeries, procedures, or medicines
• History of other diseases and conditions
• Age and general health
• Family history of CAD, heart attack, or other heart diseases

Medicines and other medical procedures may be tried before CABG. Medicines that lower cholesterol levels and blood pressure and improve blood flow through the coronary arteries are often tried.

A procedure called coronary angioplasty (also called balloon angioplasty) may be tried. During this procedure, a thin tube with a balloon or other device on the end is threaded through a blood vessel in your groin (upper thigh) or arm up to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque against the wall of the artery, widening the artery and restoring the flow of blood through it. In many cases, after the initial balloon angioplasty, a tiny mesh tube called a stent is inserted permanently in the area to keep the artery open.

What To Expect Before Coronary Artery Bypass Grafting

Tests may be done to prepare you for coronary artery bypass grafting, including blood tests, ECG, echocardiogram, chest x ray, cardiac catheterization, and angiography.

Your doctor will give you specific instructions about how to prepare for surgery. There will be instructions about what to eat or drink, what medicines to take, and what activities to stop (such as smoking). You will likely be admitted to the hospital on the same day as the surgery.

What To Expect During Coronary Artery Bypass Grafting

Coronary artery bypass grafting (CABG) requires a team of experts. A cardiothoracic surgeon performs the surgery with support from an anesthesiologist, perfusionist (heart-lung machine specialist), other surgeons, and nurses.

There are several different types of CABG. They range from traditional surgery in which the chest is opened to reach the heart, to a nontraditional surgery in which small incisions are made to bypass the narrowed artery.

Traditional Coronary Artery Bypass Grafting

This type of surgery usually lasts 3 to 5 hours, depending on the number of arteries being bypassed. Numerous steps take place during traditional CABG.

Anesthesia is given to put you to sleep. During the surgery, the anesthesiologist monitors your heartbeat, blood pressure, oxygen levels, and breathing. A breathing tube is placed in your lungs through your throat, and connected to a ventilator (breathing machine).

An incision is made down the center of your chest. The chest bone is then cut and your ribcage is opened so that the surgeon can get to your heart.

Medicines are used to stop your heart, which allows the surgeon to operate on it while it’s not beating. A heart-lung machine keeps oxygen-rich blood moving throughout your body. An artery or vein is taken from a different part of your body, such as your chest or leg, and prepared to be used as a graft for the bypass. In surgery with several bypasses, a combination of both artery and vein grafts is commonly used.

• Artery grafts. These grafts are much less likely than vein grafts to become blocked over time. The left internal mammary artery is most commonly used for an artery graft. It’s located inside the chest close to the heart. Arteries from the arm or other places in the body are sometimes used as well.
• Vein grafts. Although veins are commonly used as grafts, they’re more likely than artery grafts to develop plaque and become blocked over time. The saphenous vein—a long vein running along the inner side of the leg—is typically used.

After the grafting is complete, your heart is restarted using mild electric shocks. You’re disconnected from the heart-lung machine. Tubes are inserted into your chest to drain fluid.

The surgeon uses wires that stay in your body permanently to close your chest bone and stitches or staples to close the skin incision. The breathing tube is removed when you’re able to breathe without it.

Nontraditional Coronary Artery Bypass Grafting

Nontraditional CABG includes off-pump CABG and minimally invasive CABG.

Off-Pump Coronary Artery Bypass Grafting

This type of surgery can be used to bypass any of the coronary arteries. Off-pump CABG also is called beating heart bypass grafting because the heart isn’t stopped and a heart-lung machine isn’t used. Instead, the part of the heart where grafting is being done is steadied with a mechanical device.

Off-pump CABG may reduce complications that can occur when a heart-lung machine is used, especially in people who have had a stroke or “mini-strokes” in the past, who are over age 70, and who have diabetes, lung disease, or kidney disease.

Other advantages of this type of bypass surgery include:

• Reduced bleeding during surgery and a lower chance of needing a blood transfusion
• A lower chance of infection, stroke, and kidney complications
• A lower chance of complications such as memory loss, difficulty concentrating, or difficulty thinking clearly
• Faster recovery from the surgery

Minimally Invasive Direct Coronary Artery Bypass Grafting

There are several types of minimally invasive direct coronary artery bypass (MIDCAB) grafting. These types of surgery differ from traditional bypass surgery because they only require small incisions rather than opening the chest bone to get to the heart. These procedures sometimes use a heart-lung machine.

MIDCAB procedure. This procedure is used when only one or two coronary arteries need to be bypassed. A series of small incisions is made between your ribs on the left side of your chest, directly over the artery to be bypassed. The incisions are usually about 3 inches long. (The incisions made in traditional CABG are at least 6 to 8 inches long.) The left internal mammary artery is most often used for the graft. A heart-lung machine isn’t used during this procedure.

Port-access coronary artery bypass procedure. This procedure is performed through small incisions (ports) made in your chest. Artery or vein grafts are used. The heart-lung machine is used during this procedure.

Robot-assisted technique. This type of procedure allows for even smaller, keyhole-sized incisions. A small video camera is inserted in one incision to show the heart, while the surgeon uses remotely controlled surgical instruments to perform the surgery. The heart-lung machine is sometimes used during this procedure.

Advantages of minimally invasive CABG include smaller incisions, smaller scars, shorter recovery and hospital stay, less bleeding, less chance for infection, and less pain.

What To Expect After Coronary Artery Bypass Grafting Recovery in the Hospital

After surgery, you will typically spend 1 or 2 days in an intensive care unit. Your heart rate and blood pressure will be continuously monitored during this time. Intravenous medicines (medicines injected through a vein) are often given to regulate blood circulation and blood pressure. You will then be moved to a less intensive care area of the hospital for 3 to 5 days before going home.

Recovery at Home

Your doctor will give you specific instructions for recovering at home, especially concerning:

• How to care for your healing incisions
• How to recognize signs of infection or other complications
• When to call the doctor immediately
• When to make followup appointments

You may also receive instructions on how to deal with common after-effects from surgery. After-effects often go away within 4 to 6 weeks after surgery, but may include:

• Discomfort or itching from healing incisions
• Swelling of the area where an artery or vein was taken for grafting
• Muscle pain or tightness in the shoulders and upper back
• Fatigue (tiredness), mood swings, or depression
• Difficulty sleeping or loss of appetite
• Constipation
• Chest pain around the site of the chest bone incision (more frequent with the traditional surgery)

Full recovery from traditional CABG may take 6 to 12 weeks or more. Less recovery time is needed for nontraditional CABG.

Your doctor will provide instructions on resuming physical activity. This varies from person to person, but there are some typical timeframes. Most people can resume sexual activity within about 4 weeks and driving after 3 to 8 weeks.

Returning to work after 6 weeks is common unless the job involves specific and demanding physical activity. Some people may need to find less physically demanding types of work or work a reduced schedule at first.

Ongoing Care

Care after surgery may include periodic checkups with doctors. During these visits, tests may be done to see how the heart is working. Tests may include ECG, stress testing, and echocardiogram.

CABG is not a cure for coronary artery disease (CAD). You and your doctor may develop a management plan that includes lifestyle changes to help you stay healthy and reduce the chances of CAD getting worse. Lifestyle changes may include quitting smoking, making changes in your diet, getting regular exercise, and lowering and managing stress.

In some cases, your doctor may refer you to a cardiac rehabilitation (rehab) program. These programs can help you recover through supervised physical activity and education on how to make choices that reduce your risk for future heart problems and help you get back to your regular lifestyle after surgery.

Doctors supervise these programs, which include counseling about lifestyle changes as well as exercise training to build strength and energy. Cardiac rehab programs may be offered in hospitals and other community facilities. Ask your doctor whether you’re a candidate for cardiac rehab.

Taking medicines as prescribed also is an important part of care after surgery. Medicines may be prescribed to manage pain during recovery; lower cholesterol, blood pressure, and the chance of developing blood clots; manage diabetes; or treat depression.

What Are the Risks of Coronary Artery Bypass Grafting?

Although complications from coronary artery bypass grafting (CABG) are uncommon, the risks include:

• Wound infection and bleeding
• Anesthesia reactions
• Fever
• Pain
• Stroke, heart attack, or even death

Some patients can develop a fever associated with chest pain, irritability, and decreased appetite. This is due to inflammation involving the lung and heart sac, and is sometimes seen 1 to 6 weeks after surgeries that involve cutting through the pericardium (the outer covering of the heart). This reaction is usually a mild, self-limited illness, but some patients may develop fluid buildup around the heart that requires treatment.

Use of the heart-lung machine also can cause complications. Memory loss and other changes, such as difficulty concentrating or thinking clearly, may occur in some people. These changes are more likely to occur in people who are older, who have high blood pressure or lung disease, or who drink excessive amounts of alcohol. These side effects often improve several months after surgery.

The heart-lung machine also increases the risk of blood clots forming in your blood vessels. Clots can travel to the brain or other parts of the body and block the flow of blood, which can cause stroke or other problems. Recent technical improvements in heart-lung machines are helping to reduce the risk of blood clots forming.

In general, the chances of developing complications are higher when CABG is done in an emergency situation (for example, if performed during a heart attack), if you’re over age 70, or if you have a history of smoking. Your risks also are higher if you have other diseases or conditions such as diabetes, kidney disease, lung disease, or peripheral vascular disease.

Key Points

• Coronary artery bypass grafting (CABG) is a type of surgery used to improve blood flow to the heart in people with severe coronary artery disease (CAD).
• During CABG, a healthy artery or vein from another part of the body is connected, or grafted, to a blocked coronary artery. The grafted artery or vein bypasses (that is, it goes around) the blocked portion of the coronary artery. This improves the flow of blood and oxygen to your heart muscle.
• CABG is one type of treatment for CAD. Not everyone with CAD needs CABG. In people who are candidates for the surgery, the results are usually excellent, with 85 percent of people having significantly reduced symptoms, less risk for future heart attacks, and a decreased chance of dying within 10 years following the surgery.
• Your doctor will determine if you’re a candidate for CABG based on a number of factors, including the presence and severity of CAD. Often nonsurgical treatments, such as medicines and angioplasty, will be tried first.
• Although the surgery is usually done on an elective (scheduled) basis, it may need to be performed in an emergency, such as pending or during a heart attack.
• Although complications are rare, risks of CABG include infection at the incision site, bleeding, reactions to the anesthesia, fever and pain, stroke, heart attack, or even death.
• Recovery may take 6 to 12 weeks or more. Most people can get back to their normal activities about 6 weeks after the surgery.
• Care after surgery may include followup visits with doctors, lifestyle changes to prevent further progression of CAD, and taking medicines as prescribed.

GLAUCOMA TREATMENTS

Glaucoma is a major cause of loss of vision. Immediate treatment for early stage, open-angle glaucoma can delay progression of the disease. That's why early diagnosis is very important.

Glaucoma treatments include medicines, laser trabeculoplasty, conventional surgery, or a combination of any of these. While these treatments may save remaining vision, they do not improve sight already lost from glaucoma.

Medicines

Medicines, in the form of eyedrops or pills, are the most common early treatment for glaucoma. Some medicines cause the eye to make less fluid. Others lower pressure by helping fluid drain from the eye.

Before you begin glaucoma treatment, tell your eye care professional about other medicines you may be taking. Sometimes the drops can interfere with the way other medicines work.

Glaucoma medicines may be taken several times a day. Most people have no problems. However, some medicines can cause headaches or other side effects. For example, drops may cause stinging, burning, and redness in the eyes.

Many drugs are available to treat glaucoma. If you have problems with one medicine, tell your eye care professional. Treatment with a different dose or a new drug may be possible.

Because glaucoma often has no symptoms, people may be tempted to stop taking, or may forget to take, their medicine. You need to use the drops or pills as long as they help control your eye pressure. Regular use is very important.

Make sure your eye care professional shows you how to put the drops into your eye.

Laser trabeculoplasty

Laser trabeculoplasty helps fluid drain out of the eye. Your doctor may suggest this step at any time. In many cases, you need to keep taking glaucoma drugs after this procedure.

Laser trabeculoplasty is performed in your doctor's office or eye clinic. Before the surgery, numbing drops will be applied to your eye. As you sit facing the laser machine, your doctor will hold a special lens to your eye. A high-intensity beam of light is aimed at the lens and reflected onto the meshwork inside your eye. You may see flashes of bright green or red light. The laser makes several evenly spaced burns that stretch the drainage holes in the meshwork. This allows the fluid to drain better.

Like any surgery, laser surgery can cause side effects, such as inflammation. Your doctor may give you some drops to take home for any soreness or inflammation inside the eye. You need to make several followup visits to have your eye pressure monitored.

If you have glaucoma in both eyes, only one eye will be treated at a time. Laser treatments for each eye will be scheduled several days to several weeks apart.

Studies show that laser surgery is very good at reducing the pressure in some patients. However, its effects can wear off over time. Your doctor may suggest further treatment.

Conventional surgery

Conventional surgery makes a new opening for the fluid to leave the eye. Your doctor may suggest this treatment at any time. Conventional surgery often is done after medicines and laser surgery have failed to control pressure.

Conventional surgery is performed in an eye clinic or hospital. Before the surgery, you will be given medicine to help you relax. Your doctor will make small injections around the eye to numb it. A small piece of tissue is removed to create a new channel for the fluid to drain from the eye.

For several weeks after the surgery, you must put drops in the eye to fight infection and inflammation. These drops will be different from those you may have been using before surgery.

As with laser surgery, conventional surgery is performed on one eye at a time. Usually the operations are four to six weeks apart.

Conventional surgery is about 60 to 80 percent effective at lowering eye pressure. If the new drainage opening narrows, a second operation may be needed. Conventional surgery works best if you have not had previous eye surgery, such as a cataract operation.

In some instances, your vision may not be as good as it was before conventional surgery. Conventional surgery can cause side effects, including cataract, problems with the cornea, and inflammation or infection inside the eye. The buildup of fluid in the back of the eye may cause some patients to see shadows in their vision. If you have any of these problems, tell your doctor so a treatment plan can be developed.

Cataracts & Cataract Surgery

What is a cataract?

A cataract is a clouding of the lens in the eye that affects vision. Most cataracts are related to aging. Cataracts are very common in older people. By age 80, more than half of all Americans either have a cataract or have had cataract surgery.

A cataract can occur in either or both eyes. It cannot spread from one eye to the other.

How do cataracts develop?

Age-related cataracts develop in two ways:

1. Clumps of protein reduce the sharpness of the image reaching the retina.

The lens consists mostly of water and protein. When the protein clumps up, it clouds the lens and reduces the light that reaches the retina. The clouding may become severe enough to cause blurred vision. Most age-related cataracts develop from protein clumpings.

When a cataract is small, the cloudiness affects only a small part of the lens. You may not notice any changes in your vision. Cataracts tend to "grow" slowly, so vision gets worse gradually. Over time, the cloudy area in the lens may get larger, and the cataract may increase in size. Seeing may become more difficult. Your vision may get duller or blurrier.

2. The clear lens slowly changes to a yellowish/brownish colour, adding a brownish tint to vision.

As the clear lens slowly colors with age, your vision gradually may acquire a brownish shade. At first, the amount of tinting may be small and may not cause a vision problem. Over time, increased tinting may make it more difficult to read and perform other routine activities. This gradual change in the amount of tinting does not affect the sharpness of the image transmitted to the retina.

If you have advanced lens discoloration, you may not be able to identify blues and purples. You may be wearing what you believe to be a pair of black socks, only to find out from friends that you are wearing purple socks.

Who is at risk for cataract?

The risk of cataract increases as you get older. Other risk factors for cataract include:

• Certain diseases (for example, diabetes).
• Personal behaviour (smoking, alcohol use).
• The environment (prolonged exposure to ultraviolet sunlight).

What are the symptoms of a cataract?

The most common symptoms of a cataract are:

• Cloudy or blurry vision.
• Colors seem faded.
• Glare. Headlights, lamps, or sunlight may appear too bright. A halo may appear around lights.
• Poor night vision.
• Double vision or multiple images in one eye. (This symptom may clear as the cataract gets larger.)
• Frequent prescription changes in your eyeglasses or contact lenses.

These symptoms also can be a sign of other eye problems. If you have any of these symptoms, check with your eye care professional.

Are there other types of cataract?

Yes. Although most cataracts are related to aging, there are other types of cataract:

• Secondary cataract. Cataracts can form after surgery for other eye problems, such as glaucoma. Cataracts also can develop in people who have other health problems, such as diabetes. Cataracts are sometimes linked to steroid use.


• Traumatic cataract. Cataracts can develop after an eye injury, sometimes years later.


• Congenital cataract. Some babies are born with cataracts or develop them in childhood, often in both eyes. These cataracts may be so small that they do not affect vision. If they do, the lenses may need to be removed.


• Radiation cataract. Cataracts can develop after exposure to some types of radiation.

How is a cataract detected?

Cataract is detected through a comprehensive eye exam that includes:

• Visual acuity test. This eye chart test measures how well you see at various distances.


• Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours.


• Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to your eye for this test.

Your eye care professional also may do other tests to learn more about the structure and health of your eye.

How is a cataract treated?

The symptoms of early cataract may be improved with new eyeglasses, brighter lighting, anti-glare sunglasses, or magnifying lenses. If these measures do not help, surgery is the only effective treatment. Surgery involves removing the cloudy lens and replacing it with an artificial lens.

A cataract needs to be removed only when vision loss interferes with your everyday activities, such as driving, reading, or watching TV. You and your eye care professional can make this decision together. Once you understand the benefits and risks of surgery, you can make an informed decision about whether cataract surgery is right for you. In most cases, delaying cataract surgery will not cause long-term damage to your eye or make the surgery more difficult. You do not have to rush into surgery.

Sometimes a cataract should be removed even if it does not cause problems with your vision. For example, a cataract should be removed if it prevents examination or treatment of another eye problem, such as age-related macular degeneration or diabetic retinopathy.

If you choose surgery, your eye care professional may refer you to a specialist to remove the cataract.

If you have cataracts in both eyes that require surgery, the surgery will be performed on each eye at separate times, usually four to eight weeks apart.

Is cataract surgery effective?

Cataract removal is one of the most common operations performed in the United States. It also is one of the safest and most effective types of surgery. In about 90 percent of cases, people who have cataract surgery have better vision afterward.

Are there different types of cataract surgery?

There are two types of cataract surgery. Your doctor can explain the differences and help determine which is better for you:

• Phacoemulsification, or phaco. A small incision is made on the side of the cornea, the clear, dome-shaped surface that covers the front of the eye. Your doctor inserts a tiny probe into the eye. This device emits ultrasound waves that soften and break up the lens so that it can be removed by suction. Most cataract surgery today is done by phacoemulsification, also called "small incision cataract surgery."


• Extracapsular surgery. Your doctor makes a longer incision on the side of the cornea and removes the cloudy core of the lens in one piece. The rest of the lens is removed by suction.

After the natural lens has been removed, it often is replaced by an artificial lens, called an intraocular lens (IOL). An IOL is a clear, plastic lens that requires no care and becomes a permanent part of your eye. Light is focused clearly by the IOL onto the retina, improving your vision. You will not feel or see the new lens.

Some people cannot have an IOL. They may have another eye disease or have problems during surgery. For these patients, a soft contact lens, or glasses that provide high magnification, may be suggested.

What are the risks of cataract surgery?

As with any surgery, cataract surgery poses risks, such as infection and bleeding. Before cataract surgery, your doctor may ask you to temporarily stop taking certain medications that increase the risk of bleeding during surgery. After surgery, you must keep your eye clean, wash your hands before touching your eye, and use the prescribed medications to help minimize the risk of infection. Serious infection can result in loss of vision.

Cataract surgery slightly increases your risk of retinal detachment. Other eye disorders, such as high myopia (nearsightedness), can further increase your risk of retinal detachment after cataract surgery. One sign of a retinal detachment is a sudden increase in flashes or floaters. Floaters are little "cobwebs" or specks that seem to float about in your field of vision. If you notice a sudden increase in floaters or flashes, see an eye care professional immediately. A retinal detachment is a medical emergency. If necessary, go to an emergency service or hospital. Your eye must be examined by an eye surgeon as soon as possible. A retinal detachment causes no pain. Early treatment for retinal detachment often can prevent permanent loss of vision. The longer the retina stays detached, the less likely you will regain good vision once you are treated. Even if you are treated promptly, some vision may be lost.

Talk to your eye care professional about these risks. Make sure cataract surgery is right for you.

What if I have other eye conditions and need cataract surgery?

Many people who need cataract surgery also have other eye conditions, such as age-related macular degeneration or glaucoma. If you have other eye conditions in addition to cataract, talk with your doctor. Learn about the risks, benefits, alternatives, and expected results of cataract surgery.

What happens before surgery?

A week or two before surgery, your doctor will do some tests. These tests may include measuring the curve of the cornea and the size and shape of your eye. This information helps your doctor choose the right type of IOL.

You may be asked not to eat or drink anything 12 hours before your surgery.

What happens during surgery?

At the hospital or eye clinic, drops will be put into your eye to dilate the pupil. The area around your eye will be washed and cleansed.

The operation usually lasts less than one hour and is almost painless. Many people choose to stay awake during surgery. Others may need to be put to sleep for a short time. If you are awake, you will have an anaesthetic to numb the nerves in and around your eye.

After the operation, a patch may be placed over your eye. You will rest for a while. Your medical team will watch for any problems, such as bleeding. Most people who have cataract surgery can go home the same day. You will need someone to drive you home.

What happens after surgery?

Itching and mild discomfort are normal after cataract surgery. Some fluid discharge is also common. Your eye may be sensitive to light and touch. If you have discomfort, your doctor can suggest treatment. After one or two days, moderate discomfort should disappear.

For a few days after surgery, your doctor may ask you to use eyedrops to help healing and decrease the risk of infection. Ask your doctor about how to use your eyedrops, how often to use them, and what effects they can have. You will need to wear an eye shield or eyeglasses to help protect your eye. Avoid rubbing or pressing on your eye.

When you are home, try not to bend from the waist to pick up objects on the floor. Do not lift any heavy objects. You can walk, climb stairs, and do light household chores.

In most cases, healing will be complete within eight weeks. Your doctor will schedule exams to check on your progress.

Can problems develop after surgery?

Problems after surgery are rare, but they can occur. These problems can include infection, bleeding, inflammation (pain, redness, swelling), loss of vision, double vision, and high or low eye pressure. With prompt medical attention, these problems usually can be treated successfully.

Sometimes the eye tissue that encloses the IOL becomes cloudy and may blur your vision. This condition is called an after-cataract. An after-cataract can develop months or years after cataract surgery.

An after-cataract is treated with a laser. Your doctor uses a laser to make a tiny hole in the eye tissue behind the lens to let light pass through. This outpatient procedure is called a YAG laser capsulotomy. It is painless and rarely results in increased eye pressure or other eye problems. As a precaution, your doctor may give you eyedrops to lower your eye pressure before or after the procedure.

When will my vision be normal again?

You can return quickly to many everyday activities, but your vision may be blurry. The healing eye needs time to adjust so that it can focus properly with the other eye, especially if the other eye has a cataract. Ask your doctor when you can resume driving.

If you received an IOL, you may notice that colors are very bright. The IOL is clear, unlike your natural lens that may have had a yellowish/brownish tint. Within a few months after receiving an IOL, you will become used to improved colour vision. Also, when your eye heals, you may need new glasses or contact lenses.

What can I do if I already have lost some vision from cataract?

If you have lost some sight from cataract or cataract surgery, ask your eye care professional about low vision services and devices that may help you make the most of your remaining vision. Ask for a referral to a specialist in low vision. Many community organisations and agencies offer information about low vision counselling, training, and other special services for people with visual impairments. A nearby school of medicine or optometry may provide low vision services.

What can I do to protect my vision?

Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay cataract. If you smoke, stop. Researchers also believe good nutrition can help reduce the risk of age-related cataract. They recommend eating green leafy vegetables, fruit, and other foods with antioxidants.

If you are age 60 or older, you should have a comprehensive dilated eye exam at least once every two years. In addition to cataract, your eye care professional can check for signs of age-related macular degeneration, glaucoma, and other vision disorders. Early treatment for many eye diseases may save your sight.

HOW TO STOP SMOKING

Smoking cessation (commonly known as quitting, or kicking the habit) is the effort to stop smoking tobacco products. Nicotine is a psychologically and physically addictive substance, and quitting smoking is commonly considered to be difficult.

Psychological and pharmacological aids are available to help people quit smoking, although success rates are relatively low.

As part of the wider tobacco control movement, there have been numerous advertising campaigns, smoking restriction policies, tobacco taxes, and other strategies to encourage people to quit smoking.

Tobacco use is a major cause of death worldwide, according to the World Health Organisation (WHO).

Statistics

• 7% of over-the-counter nicotine patch and gum quitters quit for at least six months

• A physician's advice to quit can increase quitting rate by 30% to 10% at six months

• High intensity counseling of greater than 10 minutes can increase six month quitting rates to when added to any quitting method, cold turkey or NRT (nicotine replacement therapy).

• Quitting programs involving 91 to 300 minutes of contact time can increase six month quitting rates to 28%, regardless of quitting method.

• Quitting programs involving 8 or more treatment sessions can increase six month quitting rates.

• Bupropion (Zyban) can generate quitting rates 13 percentage points above placebo rates at 6 months. This fact is stated as such in that all bupropion studies to date have included counseling or support elements (having their own proven efficacy) and bupropion has not been tested in an over-the-counter type setting.

• Allen Carr method - Easyway. Carr's clinic claims a 53 per cent success rate in helping smokers stop for at least one year.

NICOTINE REPLACEMENT THERAPY

Nicotine replacement therapy is the use of various forms of nicotine delivery methods intended to replace nicotine obtained from smoking or other tobacco usage. These products are intended for use in smoking cessation efforts to help deal with withdrawal symptoms and cravings caused by the loss of nicotine from cigarettes.

Several forms of Nicotine replacement therapy have been marketed, including the nicotine patch, inhaler, nasal spray, gum, sublingual tablet, and lozenge.

Nicotine replacement therapy is thought to be useful and beneficial for tobacco users who want to quit their addiction and is for most people perfectly safe. Cigarettes on the other hand cause the early deaths of about 5 million people each year. These people are not killed by the nicotine in the cigarette, but by other constituents of tobacco smoke such as Carbon Monoxide and tars. It is the nicotine that keeps the smoker addicted. Cigarettes can be viewed as a "dirty" and dangerous method of delivering nicotine, while Nicotine replacement therapy is a "clean" and safe method.

Nicotine replacement therapy delivers nicotine to the smokers brain in a much slower way than cigarettes do. It helps to damp down the urges to smoke that most smokers have in the early days and weeks after quitting, rather than remove them totally. It gives the smoker the chance to break smoking cues in their daily lives, and might provide a more comfortable exit from the smoking habit. Nicotine replacement therapy however is best used with some form of support, ideally from someone who knows something about smoking cessation.

A small number of people who use Nicotine replacement therapy, especially Nasal Spray and Nicotine Gum, will go on to use it on a longer term basis. These are usually highly nicotine dependent smokers who would not have been able to quit without the help of such medication. There is currently no evidence that such long term usage is harmful to health, especially when compared to smoking.

Findings from a recent Cochrane review of controlled trials testing Nicotine replacement therapy products indicated that smokers using Nicotine replacement therapy were 1.5 to 2 times more likely to be abstinent from smoking at follow-up than those in the placebo or control treatment condition.

Types:

• Nicotine patch
• Nicotine gum
• Nicotine lozenge
• Nicotine inhaler
• Nicotine spray
• Nicotine sublingual tablet

HYPNOSIS AND HYPNOTHERAPY

What is hypnosis?

Hypnosis is a natural psychological process in which critical thinking faculties of the mind are bypassed and a type of selective thinking and perception is established. Although some individuals experience an increase in suggestibility and/or subjective feelings of an altered state of consciousness, this is not true for everyone.

Hypnotherapy is a term to describe the use of hypnosis in a therapeutic context. Many hypnotherapists refer to their practice as "clinical work". Hypnotherapy can either be used as an addition to the work of licensed physicians or psychologists, or it can be used in a stand-alone environment where the hypnotherapist in question usually owns his or her own business.

The majority of certified hypnotherapists today earn a large portion of their money through the cessation of smoking (often in a single session) and the aid of weight loss.

There is no evidence that 'incurable' diseases are curable with hypnosis (such as cancer, diabetes, and arthritis). However, pain and other body functions related to some diseases are controllable.

Some of the treatments practiced by hypnotherapists, in particular so-called regression, are viewed with skepticism.

Hypnotherapy Techniques

• Age regression - by returning to an earlier ego-state the patient can regain qualities they once had, but have lost. Remembering an earlier, healthier, ego-state can increase the patients' strength and confidence.
• Revivification - remembering past experiences can contribute to therapy. For example; the hypnotist may ask "have you ever been in trance?" and then find it easier to revive the previous experience than attempt inducing a new state.
• Guided imagery - a method by which the subject is given a new relaxing and beneficial experience.
• Parts therapy - a method pioneered by Charles Tebbetts to identify conflicting parts that are damaging the well being of clients, then helps those parts negotiate with each other through the therapist to bring about a resolution.
• Confusion - a method developed by Milton H. Erickson in which the subject is more likely to be receptive to indirect suggestion due in an altered state of confusion.
• Repetition - the more an idea is repeated the more likely it is to be accepted and acted upon by the patient.
• Direct suggestion - suggesting directly. "You feel safe and secure".
• Indirect suggestion - using "interspersal" technique and other means to cause effect.
• Mental state - people are more receptive while relaxed, sleeping, or in a trance.
• Hypnoanalysis - the client recalls moments from his past, confronting them and releasing associated emotions, similar to psychoanalysis.
• Post-hypnotic suggestion - a suggestion that will be carried out after the trance has ended. "When you re-awaken you will feel refreshed and happy!!"
• Visualization - being told to imagine or visualize a desired outcome seems to make it more likely to actually occur.

Self-hypnosis (or autosuggestion) hypnosis in which a person hypnotizes himself or herself without the assistance of another person to serve as the hypnotist is a staple of hypnotherapy-related self-help programs. It is most often used to help the self-hypnotist stay on a diet, overcome smoking or some other addiction, or to generally boost the hypnotized person's self-esteem.

TREATING HYPOGLYCAEMIA

Hypoglycaemia (low blood glucose) occurs when blood glucose levels fall below 4 mmol/L. It is commonly referred to as a 'hypo'.

Although exercise lowers the blood glucose level, it will normally not cause hypoglycaemic episodes in otherwise healthy people.

Symptoms of hypoglycaemia

Hypoglycaemia can make you feel:

- tired
- pale
- clammy/sweaty
- weak/faint
- hungry
- agitated

Diabetes-Related Hypoglycaemia

• If you think your blood glucose is low, check it and treat the problem right away.
• To treat hypoglycaemia, have a serving of a quick-fix food, wait 15 minutes, and check your blood glucose. Repeat the treatment until your blood glucose is above 4 mmol/L.
• Keep quick-fix foods in the car, at work�anywhere you spend time.
• Be careful when you are driving. Check your blood glucose frequently and snack as needed to keep your level above 4 mmol/L.

Hypoglycaemia Unrelated to Diabetes

• In reactive hypoglycaemia, symptoms occur within 4 hours of eating. People with this condition are usually advised to follow a healthy eating plan recommended by a registered dietitian.
• Fasting hypoglycaemia can be caused by certain medications, critical illnesses, hereditary enzyme or hormonal deficiencies, and some kinds of tumours. Treatment targets the underlying problem.