Heartburn

Heartburn is the common classical symptom of the disorder gastro-oesophageal reflux disease (GORD). Heartburn is experienced as a gripping, substernal (below the breastbone) discomfort that may be made worse by lying, eating or bending. In some cases heartburn may be confused with cardiac chest pain but the former is relieved by antacids whilst pain associated with ischaemic heart disease is relieved by nitrate sprays.

Heartburn is extremely common in the Australian population and is most cases can be easily managed with simple lifestyle changes and over-the-counter antacid medications. However, if the pain is persistent you may require further investigations as severe disease can progress to adenocarcinoma of the oesophagus. This is a type of cancer that develops in a very small number of patients.

Heartburn is the hallmark symptom of gastro-oesphageal reflux disease (GORD) and a common complaint amongst the general population. Heartburn is described as an intermittent retrosternal (behind the breastbone) burning discomfort that is exacerbated by eating, lying down, bending, stooping or straining. The pain is typically central but it may spread across the chest and into the neck and may be mistaken for the pain associated with ischaemic heart disease.

Virtually everyone will experience some mild heartburn at some time during their lives whilst up to 20% of the population will experience it weekly and 40% on a monthly basis. Doctors are faced with the challenge of deciding who needs further investigation for this extremely common complaint to identify those patients with gastro-oesophageal reflux that may progress to oesophagitis (erosion and destruction of the lining of the oesophagus), cellular morphological changes (called Barrett's oesophagus) and occasionally adenocarcinoma.

As forementioned, heartburn is commonly caused by gastro-oesophageal reflux disease. In this disorder the sphincter mechanism at the lower end of the oesophagus (the tube from the back of your throat to your stomach) is faulty. This means that when food enters the stomach, the gap between the oesophagus and stomach doesn't close properly and food can move backwards (reflux) into the oesophagus. This causes damage to the oesophagus and pain because the lining of the oesophagus is not designed to withstand the acidic environment of the stomach. In addition, the muscular walls are thought to spasm when food is refluxed further contributing to pain.

There are a number of conditions that can predispose to dysfunction of the lower oesophageal sphincter or make heartburn symptoms worse. These include:

Hiatus hernia- In this condition the top part of the stomach pushes up through a defect in the diaphragm (a muscular structure dividing the chest from the abdomen). This causes weakening of the sphincter and upsets the stomach's closure mechanisms. Food is more likely to propel back from the stomach to the oesophagus. Obesity. Pregnancy- Presumably predisposes to reflux due to increased abdominal pressure and loosening of ligaments and muscles (including those of the sphincter mechanism in the diaphragm) in the body in preparation for childbirth. Smoking and alcohol consumption. Medications- Certain medications used to treat blood pressure problems, depression or asthma have been associated with heartburn symptoms. If you suspect one of your medications is causing heartburn do not hesitate to consult your doctor.

In many cases the doctor can make the diagnosis of your condition from history of your symptoms alone. They will ask you detailed questions about the location of the pain and whether it spreads anywhere. The timing of the pain in relationship to meals, effects of posture and duration of the pain is also important information. Your doctor will also ask questions about your diet, smoking, alcohol and current medications. You will also be questioned about other symptoms such as blood or black material in your vomit or stools. In particular, weight loss and difficulty swallowing are important symptoms as they may suggest a serious problem.

Not all patients will have the classic symptoms of heartburn and sometimes your symptoms may seem more like a respiratory problem such as a cough or wheeze at night. Along with chest discomfort you may also have other symptoms of oesophageal dysfunction including:

Difficulty swallowing. Painful swallowing due to damage to the lining of the oesophagus. Acid regurgitation. Excessive salivation.

Unfortunately the severity of your symptoms does not correspond well with the severity of the damage to your oesophagus. This is a problem if patients have mild symptoms but there is extensive damage that may progress to more sinister conditions.

In many cases no further investigation is required, particularly if you are young with longstanding classic symptoms of heartburn. However, if you are older or you doctor is concerned they may order further tests to confirm the diagnosis of reflux and grade the severity.

These tests may include:

Upper gastrointestinal endoscopy and biopsy (tissue sampling)- This lets the doctor visualise damaged areas. Tissue samples can help exclude early precancerous changes. Barium studies- This may detect a hiatus hernia. Manometry- A tube is inserted down the nose to measure the pressures generated by the lower oesophageal sphincter. Oesophageal pH monitoring- This is done over a 24 hour period with a special device positioned in the lower oesophagus. The device can detect reflux episodes by the degree of acidity.

In most cases the main aim of treatment will be to relieve your symptoms. However in some cases the doctor may be more concerned that the oesophagus is completely healed, particularly if you have severe disease or are at risk of complications. In these cases follow-up endoscopies and biopsies may be needed. At least half of patients will respond to lifestyle changes and simple antacid medications.

Lifestyle changes

Lose weight if overweight. Raise the head of the bed- Placing blocks or bricks securely under the legs of the head of the bed can reduce the risk of stomach contents flowing back up into the oesophagus. Eat small, regular meals and avoid intake of food or beverages within three hours of bedtime. Avoid lying, bending or exercising just after eating. Avoid drugs such as NSAIDs that damage the oesophageal mucosa and drugs that impair oesophageal motility (nitrites, anticholinergics, certain antidepressants etc.). ask your doctor for advice regarding your current medications. Avoid smoking and alcohol. Avoid foods that are known to exacerbate your symptoms such as spicy foods, tomatoes, citris fruits and peppermint. Reduce stress.

Medications

If the above measures don't work you can try medications such as:

Antacids: For example Mylanta can neutralise stomach acid and is available at chemists and supermarkets. They can however alter bowel motions and cause fluid retention. Alginates: These are also over-the-counter drugs and work by forming a gel or 'foam raft' on top of the stomach contents to provide a physical barrier to reflux. If the above two types of drugs do not relieve symptoms within four weeks it is best to see a doctor who may arrange an endoscopy investigation (tube with a camera down the throat to have a look). Acid suppression therapy: Your doctor can prescribe two classes of drugs called H2-receptor antagonist or Proton-pump inhibitors (PPIs) which markedly reduce acid production. The latter is the best treatment for severe disease and can be used long-term to prevent recurrence. Your doctor may also try agents that speed up the stomach's emptying activity to reduce reflux.

Surgery

In a small number of patients surgery is indicated. This is only suitable if you have very severe symptoms of heartburn and the condition is confirmed by radiology or pH-monitoring. Surgery is normally done laparoscopically (key-hole surgery) and aims to fix defects in the diaphragm and sphincter mechanism. This may be considered a favourable option for young patients who would require long-term maintenance therapy.

For more information on acid reflux and heartburn and related investigations, treatments and supportive care, see Acid Reflux and Heartburn. de Caestecker J. ABC of the upper gastrointestinal tract. Oesophagus: Heartburn. BMJ. 2001;323(7315):736-9. [Abstract | Full text]Cohen S, Parkman HP. Heartburn: A serious symptom. N Engl J Med. 1999;340(11):878-9. [Abstract]Kumar P, Clark M (eds). Clinical Medicine (5th edition). Edinburgh: WB Saunders Company; 2002. [Publisher] Longmore M, Wilkinson I, Rajagopalan S. Oxford Handbook of Clinical Medicine (6th edition). Oxford: Oxford University Press; 2004. [Publisher] Longstreth GF. Heartburn [online]. Bethesday, MD: MedlinePlus; 2005. Available from: URL link Talley N, Moore M, Sprogis A, Katelaris P. Randomised controlled trial of pantoprazole versus ranitidine for the treatment of uninvestigated heartburn in primary care. Med J Aust. 2002;177(8):423-7. [Abstract | Full text] Product Information: Somac Heartburn Relief Tablets. North Ryde, NSW: Nycomed Pty Ltd; 31 July 2008.Fox M. Gastro-oesophageal reflux disease. Clinical review. BMJ. 2006; 332: 88-93. [Abstract | Full text]
Duggan AE. The management of upper gastrointestinal symptoms- is endoscopy indicated? Med J Aust. 2007; 186(4): 166-7. [Full Text]Braunwald E, Fauci AS, Kasper DL, et al. Harrison's Principles of Internal Medicine (15th edition). New York: McGraw-Hill Publishing; 2001. [Publisher]Tierney LM, McPhee SJ, Papadakis MA (eds). Current Medical Diagnosis and Treatment (45th edition). New York: McGraw-Hill; 2006. [Publisher]DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005; 100(1): 190-200. [Abstract]Murtagh J. General Practice (3rd edition). Sydney: McGraw-Hill; 2003. [Publisher]

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Diaphragm

The diaphragm, which was developed in the 19th century, is one of the oldest methods of preventing pregnancy. It is a latex dome which is inserted into a woman's vagina prior to sexual intercourse. Silicon diaphragms are also available for women who are allergic to latex.

The dome is placed so that it covers the woman's cervix, and thus creates a barrier which prevents sperm from entering the uterus. A flexible spring, found in the rim of the diaphragm, prevents the dome from moving out of place during intercourse.

The device must be fitted by a health professional, to ensure the correct size diaphragm is selected, however once a diaphragm has been fitted, a woman can easily insert and remove the diaphragm before and after sexual intercourse. Diaphragms are typically used in conjunction with spermicides to increase their effectiveness.

The diaphragm prevents pregnancy by blocking the cervical opening (the entrance to the uterus). It therefore prevents sperm from entering the uterus. If a woman is fertile, (if she has a viable egg in her uterus) sperm must enter the uterus to fertilise the egg. The egg cannot be fertilised once it has been expelled into the vagina. Thus, by preventing sperm from entering the uterus, the diaphragm also prevents sperm coming into contact with and fertilising an egg.

Most women can safely use a diaphragm. However, some women may need to delay diaphragm use, and use a different method until they can safely use a diaphragm. These women include:

Those who have experienced a second trimester miscarriage or abortion should wait for at least six weeks before having a diaphragm fitted;Those who have recently given birth should wait until at least six weeks after childbirth to have a diaphragm fitted;Those with uterine abnormalities, including uterine prolapse. These women should discuss other contraceptive methods which might be more suitable with their healthcare provider so that they can choose another method;Those with latex allergies should not use a latex diaphragm. A silicon diaphragm may be appropriate, or the woman's healthcare provider will be able to give advice about other contraceptive methods.

In addition, a diaphragm should not be used by the following women

Women with a history of toxic shock syndrome - as diaphragms increase the risk of this condition. Women who have previously experienced toxic shock syndrome should discuss other, more appropriate contraceptive methods with their healthcare provider. They should also not use a cervical cap);Women who have a high risk of HIV - as a diaphragm is typically and most effectively used in conjunction with spermicide, and commonly available spermicides increase the risk of HIV infection, diaphragm use may increase a woman's HIV risk. Women who are at risk of HIV infection, for example those who have sex with partners whose HIV status is unknown, should use condoms if possible, as these reduce the risk of HIV infection and other sexually transmitted infections. (For some women find it is difficult to use condoms, for example if their partners refuse, there are pregnancy prevention methods which they can use without their partner's knowledge including hormonal contraceptive injections or implants, or a diaphragm. However, these methods do not protect against STIs.)

The Sex in Australia survey, a national study of sexual experiences and behaviours of Australians, reported that 0.9% of Australian women used a diaphragm.

When used correctly and in conjunction with spermicide during every act of sexual intercourse, the diaphragm prevents pregnancy in 94% of cases. However, most women do not use the diaphragm correctly every time they have sex, and as typically used, its effectiveness is much lower, around 84%.

It is very important for a diaphragm user to know how to use the device correctly. The health practitioner who fits the diaphragm will explain to the woman how a diaphragm is used, when they do the fitting.

Your health practitioner may recommend that new users begin by using their diaphragm in conjunction with another method. This is not because diaphragms do not work when they are first fitted, but rather to allow the woman to get used to inserting and removing the device correctly.

Diaphragm users should also be aware that:

For effective use, a diaphragm must be used prior to every act of intercourse;When a diaphragm is correctly inserted, the woman should not be able to feel it, even during intercourse;That diaphragms are most effective when used in conjunction with spermicides;That diaphragms have some side effects, the most common of which are urinary tract infections and vaginal discharges (see below).

Diaphragms must be fitted by a health professional. To select a diaphragm of the correct size, the health provider will conduct a pelvic examination. The health provider will first assess the woman's uterine cavity for any conditions which may make the diaphragm an unsuitable contraceptive method for the woman. The practitioner will then insert their index and middle finger into the woman's vagina to determine the required diaphragm size. A diaphragm will then be selected and inserted into the woman's vagina by the health practitioner, so that it covers the cervix. The practitioner will then check that the device fits correctly.

Women using diaphragms should be aware that a new diaphragm must be fitted after childbirth or a second trimester abortion. A new diaphragm should also be fitted if the woman experiences weight gain of >5kg. Women who do not need to have a new diaphragm refitted should replace their device every two years.

The diaphragm must be inserted prior to each act of intercourse. The health practitioner who fits the device will explain to women who are new users of the diaphragm, how to use the device. They may also give the women additional information about her genital organs, which will assist her to correctly insert the device. For example the health practitioner may show women the position of the cervix and pubic bone, using a diagram or model.

To correctly insert a diaphragm a woman should:

Begin by washing her hands;Check the diaphragm for cracks by holding it up to the light;Insert spermicide into the dome and around the rim of the diaphragm. It is important to always check the expiry date of spermicides before using them;Press the rims of the diaphragm together and insert the device deep into the vagina. The woman should choose a comfortable position for insertion, for example lying down;Insert her finger into her vagina and feel to check that the diaphragm is in the correct position, that it is covering the cervix. The cervix feels similar to the tip of the nose, and can be felt through the diaphragm;Remove and reinsert the diaphragm if she can feel it inside her vagina when she moves;If the woman has sexual intercourse several times, she should not remove and reinsert the diaphragm between sex acts. Rather the diaphragm should be left in place and additional spermicide added each time.

It is very important that the diaphragm is left in place for at least six hours following intercourse, but not for more than 24 hours. Leaving the diaphragm in place for more than 24 hours may result in unpleasant odour or vaginal discharge, and in rare cases, toxic shock syndrome. Once at least six hours has elapsed since the last sexual intercourse, a woman should remove the diaphragm according to the following procedure:

Before commencing, the woman should wash her hands;She should then insert a finger into her vagina until she feels the rim of the diaphragm;She should gently slide the finger under the rim and pull the diaphragm down and out. Care should be taken to ensure the diaphragm does not tear or break;Finally, she should wash the diaphragm using mild soap and water. The diaphragm should then be dried and stored in a cool dry place.

Benefits of the diaphragm include:

Use of a diaphragm is controlled by the woman and can be used without the knowledge or consent of her male partner;A diaphragm is effective even if it is inserted up to six hours before intercourse and thus can be inserted in advance to avoid disrupting sexual activity;Using a diaphragm may enable a woman to become more familiar with her genital organs, for example she will learn where her cervix is, and become more comfortable inserting her fingers into her vagina;The diaphragm is a relatively low cost contraceptive method, which does not require frequent visits to a medical practitioner.

Diaphragm use is commonly associated with urinary tract infections. This means that between 1-10% of users experience this side effects.

Candidiasis and bacterial vaginosis are uncommon side effects of diaphragm use, that is, they are side effects experienced by between 0.1%-1% of women who use the device. When the diaphragm is used in conjunction with a spermicide, these side effects are more likely.

Very rare cases of toxic shock syndrome have been reported in diaphragm users. Less that 0.01% of users experience this side effect.

Limitations of the diaphragm include:

The diaphragm must be inserted prior to every act of intercourse;The contraceptive protection of a diaphragm is much less effective than other methods (e.g. hormonal methods are typically >99% effective);To insert a diaphragm a woman must be comfortable with inserting her finger/s into her vagina. Women who have cultural or other objections to touching their genitals cannot use the method;Diaphragms do not provide adequate protection against sexually transmitted infections (STI). Women who have sexual partners of unknown STI status, should use male or female condoms if this is possible. Condoms offer high levels of protection against both pregnancy and STI.

For more information on different types of contraception, female anatomy and related health issues, see Contraception.

Association of Reproductive Health Professionals. Non-hormonal contraceptive methods- a quick reference guide for clinicians. 2007. [cited 2009, October 30] Available from: www.arhp.org/guide World Health Organisation. Family Planning: A global handbook for providers. 2007. [cited 2009, June 20] Available from:  www.who.int/entity/reproductivehealth/publications/family_planning/en/ Amy, J. Tripathi, V. Contraception for women: an evidence based review. BMJ. 2009. 339:563-8.Farmer, L. Everett, S. Nonhormonal contraception. Obstetric, gynaecological and reproductive medicine. 2007.18(2):33-8.Richters, J. Grulich, A.E. de Visser, R.O. et al. Sex in Australia: Contraceptive Practices in a representative sample of women. Aust NZ J Pub Health. 2003;27:210-6.

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Fatigue in Cancer Treatment

Fatigue is a vague yet common complaint. Fatigue can be defined as a daily lack of energy, an unusual or excessive whole-body tiredness not relieved by sleep. It can be acute (lasting a month or less) or chronic (lasting for months or longer). Fatigue can prevent a person from functioning normally and have significant impact on a person's quality of life.

Fatigue is the most frequently reported symptom of cancer and cancer treatment. Although well recognised by health professionals as a significant problem, cancer fatigue is still poorly understood. It manifests as a chronic or long-lasting sense of exhaustion and decreased ability to do normal activities that is not relieved by rest or sleep.  

There are many possible causes of fatigue, most of which are completely unrelated to cancer.

General causes 

Some general causes include:

Cancer-related causes 

How exactly cancer causes fatigue is still poorly understood.

Cancer treatments commonly associated with fatigue include:

Chemotherapy: Any chemotherapy drug may cause fatigue. For some patients, fatigue lasts only a few days, while for others it may persist throughout the course of treatment and continuing after the treatment is complete. The fatigue may be due to anaemia which chemotherapy drugs can cause. Radiotherapy: Radiotherapy can cause fatigue that increases over time. This can occur regardless of the treatment site. Fatigue usually lasts from 3 to 4 weeks after treatment stops but can continue for up to 2 to 3 months. In addition, radiation therapy to the neck area can affect the thyroid gland and cause hypothyroidism (which can contribute to fatigue). Bone marrow transplant: Bone marrow transplant can cause fatigue that lasting up to one year. Biological agents: Interferons and interleukins are cytokines, chemicals that are normally released by white blood cells in response to infection. They carry messages that regulate other elements of the immune and endocrine systems. At high levels, these cytokines can be toxic and lead to persistent fatigue. Combination therapy: if more than one type of treatment is used, eg. chemotherapy and radiotherapy, the chances of treatment related fatigue will increase.

Other factors that may contribute to cancer-related fatigue include:

Tumour-induced "hypermetabolic" state: Due to tumour cells competing for nutrients, often at the expense of the normal cells' growth. Poor nutrition: Due to weight loss and nausea from the side effects of treatments can contribute to fatigue. Other medications: Medications used to treat side effects (e.g. nausea, pain, depression, anxiety, seizures) can cause fatigue. Pain and stress: Research shows that chronic pain increases fatigue, as does stress. Depression: Depression/adjustment disorder which may be pre-existing or related to stress caused by the diagnosis of cancer.

Treating fatigue is often difficult as usually there is no obvious cause or there may be many contributing causes. When there is an obvious cause, such as anaemia or low thyroid hormone levels, then this should be treated appropriately.

Exercise

In terms of cancer related fatigue, so far the only treatment which has been proven to improve energy levels is exercise. Studies have shown that a properly designed exercise programme helps maintain muscle strength, prevent worsening fatigue, and in many people, can actually lead to an increase in energy levels. Patients should be encouraged to keep active for as long as possible, within their abilities. Physiotherapy may also help people to stay active.

Pharmacotherapy

Appetite stimulants

A number of studies have suggested that drugs can be used to treat anorexia. The most commonly used drugs include corticosteroids and progesterone. Patients who have problems with nutritional intake may also be advised to take a high calorie diet. Referral to a dietician may be helpful.

Other drug intervention

Any treatments that relieve the effects of cancer or side effects of treatment may also affect energy levels. Effectively treating problems such as pain, nausea, anaemia or depression, is likely to have an impact on symptoms of fatigue.

Treatment of anaemia

Anaemia is a common problem in cancer patients, with frequency related to the type of cancer and the way it is being treated. There are medications available which can encourage the patient's body to produce more red blood cells, resulting in reduced anaemia-related fatigue and improvement in patient's ability to perform daily tasks.

Antidepressants

Depression or adjustment disorder can commonly occur in patients with cancer, particularly those with advanced disease. Antidepressants may be of value when patients have fatigue associated with depression.

Psychological support

Patients may receive helpful advice on managing their anxiety through professional and self-help sources, such as counselling, patient support groups, psychological support and occupational therapy. Other methods that may reduce fatigue include relaxation methods, yoga and massage. Activities such as music, humour and socialising with friends and family may help, and so may energy conserving strategies such as planning and pacing activities and work, and eliminating unnecessary tasks.

For more information on cancer, including breast, prostate, kidney and stomach cancer, see Cancer: Overview.

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An Introduction to Obesity Treatments

Obesity is a chronic health problem that has become a worldwide epidemic. Recent estimates suggest that over 70% of Australian males and fover 50% of Australian females are overweight or obese. Furthermore, rates of obesity are increasing at alarming rates due to increasingly sedentary lifestyles combined with easy access to cheap, tasty high fat foods. Rates of obesity in Australia have doubled in the last two decades to make Australia one of the fattest developed nations in the world! Of particular concern are the rising rates of obesity in children. Now almost a quarter of Australian children are considered overweight or obese.

Obesity is a serious medical condition and can lead to considerable health consequences including heart disease, diabetes, high blood pressure, high cholesterol, obstructive sleep apnoea and arthritis. Therefore it is very important that you seek appropriate treatment.

Obesity is essentially a disorder of your metabolism and is caused by an imbalance between energy intake and energy expenditure over a long period of time. In other words, you are consuming more calories or energy than you are burning through exercise and daily activities.  Treatment of obesity therefore aims to restore this energy balance.

There are numerous different treatment options available which are described briefly below. Further information can be obtained by following the links to each of the treatments. In addition you can view the following video which provides an overview of the different management options.

Traditional methods for weight loss include reducing calorie intake, increasing physical activity, and behaviour therapy. However, increasing levels of obesity and associated medical conditions has heightened interest in both pharmacological (drug) and surgical treatments for weight loss. In most cases you will be treated with a combination of therapies. The aim of therapy is to try to restore your normal weight and reduce co-morbidities without causing significant side effects or morbidity. In general, the greater the degree of weight loss achieved, the greater health benefits gained. However, even small amounts of weight loss (of 5-10% of body weight) can significantly improve your health. Therefore you should set realistic goals and be satisfied with even small amounts of weight loss.

Lifestyle modification remains the mainstay of treatment for obesity and is an essential component of all forms of weight loss programs. Lifetime changes in eating and exercise behaviour may be the only treatment that produces long term and sustained reductions in weight. Lifestyle changes can include the following components:

Dietary changes

Overall the aim of diet therapies are to reduce caloric intake. There are countless different types of commercial diets available and it is important that you find one that is suited to you and safe. Diets can be broadly categorised into reduced energy, low energy or very low energy diets based on how much they restrict your daily caloric intake. If you are severely obese and have obvious weight related medical conditions, your doctor may suggest a more restrictive very low energy diet for a short period of time. Very low energy diets can produce rapid and marked weight loss by limiting your daily intake with set meal plans, pre-prepared meals or meal replacements. However, following cessation of the program much of this weight will be regained so it is important you try to adhere to other lifestyle changes in the long term. You may also need other treatments such as drugs and behavioural therapy to help you maintain the weight loss. For this reason less restrictive diets are sometimes preferred as you have more freedom and must learn how to select and prepare healthy meal options. The long-term outcomes of the different diets are therefore quite similar.

Meal replacement programs

Recently meal replacement programs have been developed that replace normal meals with prepared meal plans or meal supplements (such as vitamin- and mineral-fortified shakes, soups and bars). These diets operate on the principles of a low calorie diet and induce a mild state of ketosis to produce weight loss. These diets limit your carbohydrate intake so your body switches to other forms of energy, in particular the fat stores in your body. Burning your fat stores eventually leads to weight loss. (Please refer to our metabolism write up for further information). These diets are specially formulated so that they provide a safe level of carbohydrates and continue to supply essential vitamins and minerals.

Physical activity

Increased physical activity is often used in conjunction with diets to increase energy expenditure. Using exercise alone for weight loss is however often unsuccessful. You can try to increase your physical activity by walking places rather than driving and climbing the stairs rather than using the escalator or lift. You should aim to engage in 30 minutes of moderate intensity exercise (such as brisk walking) at least 3-5 days per week. You should try to do activities you enjoy as this will increase the likelihood you will adhere to them in the future. If you are very obese and have difficulty exercising you could try swimming, cycling or walking in water until your fitness level improves. You may be referred to a physiotherapist or exercise physiologists to help you devise an appropriate exercise program.

Behavioural therapy

Behaviour modification methods (such as Cognitive Behavioural Therapy (CBT)) can help improve treatment compliance and improve long-term weight loss. These treatments analyse your behaviours and habits that contribute to poor eating and lack of physical activity. You are encouraged to take responsibility for your weight loss and lifestyle changes. However, these methods however can be very time consuming and expensive.

Lifestyle changes are extremely challenging and you must be highly motivated to achieve success. Most patients will achieve weight loss by the above methods but long-term maintenance of weight loss remains an issue. Approximately 90% of people will regain their weight lost in supervised programs in the next few years. Lifestyle changes however remain the most hopeful treatments for long-term weight loss if you adhere to them correctly. If you are only mildly overweight (i.e. a body mass index (BMI) less than 30), lifestyle treatments alone are often sufficient to achieve weight loss. If however you are obese (BMI greater than 30) lifestyle treatments may be insufficient to achieve satisfactory weight loss and additional treatments such as pharmacotherapy may be necessary to maintain weight loss.

Several weight loss drugs have been marketed to date which work by either suppressing the appetite (e.g. Sibutramine - Reductil) or reducing absorption of fats (e.g. Orlistat - Xenical). These drugs should always be prescribed by a medical professional. These agents can cause weight loss of up to 10% of body weight. However, following cessation of treatment much of this weight will be regained. In addition many of these drugs can have nasty side effects (such as diarrhoea) and are still being investigated in clinical trials. Some older drugs such as fenfluramine have been withdrawn form the market due to bad side effects on the heart.

In order for medications to really work, they need to be combined with lifestyle modifications such as a low fat diet and regular exercise. Medications for weight loss should only be taken for short periods (up to 3 months) and always be used with caution as they have the potential for abuse. At present they are only indicated if you are morbidly obese, have significant co-morbidities or if you have failed other lifestyle treatments.

Surgical treatments tend to be considered if you are morbidly obese (defined as a BMI greater than 40). You must however consider the operative risks associated with each of the procedures. In most cases however, the benefits to your mental and physical health and appearance will outweigh the risks of surgery. If you are markedly obese with co-morbidities, surgery is considered the only available treatment that can reliably produce significant and sustained weight loss. Surgical procedures may help you lose up to 30-40kg of excess weight; however this is only achieved if you adhere to the required lifestyle changes.

A variety of surgical procedures have been used which can be broadly classified into restrictive and mal-absorptive procedures. The former includes procedures such as the old fashioned gastroplasty and laparoscopic gastric banding. The latter is the most common procedure performed in Australia because it is safe and reversible. By means of a silicone band around the stomach, gastric banding physically limits the amount of food that can be consumed before you become full. Mal-absorptive procedures (such as gastric bypass) typically involve bypassing a segment of small intestine to reduce the absorption of calories and hence lead to weight loss. Both methods produce similar long term results in terms of weight loss with patients losing approximately 50-70% of their excess weight. However, bypass operations may be more risky and can interfere with absorption of essential vitamins and minerals.

Whilst surgery is becoming increasingly common for the treatment of obesity, diet, exercise and long-term lifestyle changes remain the cornerstone of treatment. Surgery should only be considered if you are morbidly obese with significant weight related health problems. Successful treatment of obesity therefore requires an integrated and multidisciplinary approach with input from a variety of health professionals including dieticians, physicians, physiotherapists, surgeons and psychologists/psychiatrists.

In order to achieve long term weight loss you are required to make lifetime changes in your eating and exercise behaviours. In the future, the government may also be able to help treat the obesity epidemic by altering the environment we live in. Strategies and public health campaigns to produce an environment that supports healthy eating and physical activity throughout the community are needed.

For more information on obesity, health and social issues, and methods of weight loss, as well as some useful tools, see Obesity and Weight Loss. About overweight and obesity [online]. Canberra, ACT: Australian Government Department of Health and Ageing; 2005 [cited 9 August 2007]. Available from: URL linkThe Obesity Society: Fast facts [online]. University of Sydney, NSW: Australasian Society for the Study of Obesity; 2005 [cited 9 August 2007]. Available from: URL linkFlier J, Maratos-Flier E. Chapter 242: Obesity. In: Braunwald E, Fauci AS, Kasper DL, et al (eds). Harrison's Principles of Internal Medicine (16th edition). New York: McGraw-Hill Publishing; 2006. [Book]Hamdorf J. Obesity Management [video]. Osborne Park, WA: Virtual Medical Centre; 2007 [cited 9 August 2007]. Available from: URL link Kumar P, Clark M (eds). Clinical Medicine (5th edition). Edinburgh: WB Saunders Company; 2002. [Book]Clinical practice guidelines for the management of overweight and obesity in adults [online]. Canberra, ACT: Australian Government Department of Health and Ageing; 18 September 2003 [cited 9 August 2007]. Available from: URL linkProietto J, Baur L. Management of obesity. Med J Aust. 2004;180(9):474-80. [Abstract | Full text]Wilding J. Science, medicine, and the future: Obesity treatment, BMJ. 1997;315(7114):997-1000. [Abstract | Full text]

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Gastroplasty

Gastroplasty is a weight loss operation available for the management of morbid obesity. It is a restrictive procedure in that it limits and reduces the amount of food intake possible, as opposed to the alternative procedures such as gastric bypass which work by reducing the absorption of calories through the digestive tract. Its main advantage is that is does not affect the normal digestive process, thereby limiting nutritional deficiencies which are often associated with the former procedure.

This procedure is also known as ‘stomach stapling’ as it involves vertically stapling the upper part of the stomach into a small pouch of about 20-30mL which is then connected to the rest of the stomach through an small outlet (stoma) of about 10-12mm width. At the lower end of the pouch a band or mesh is often placed to prevent the outlet from widening. The pouch restricts the amount of food that can be eaten at one time because of the slow passage of the food into the remaining stomach which subsequently helps maintain a feeling of fullness.

Gastroplasty was initially introduced in 1971 following the advent of surgical staples and was supposedly to provide a simpler and safer alternative to gastric bypass surgery which was often associated with many complications such as micronutrient deficiency and peptic ulcerations. It has had several revisions made to it since its introduction. The earliest methods involved horizontal stapling of the stomach which divided it into a smaller upper section and larger lower part which was connected by a channel. However this was unsuccessful in maintaining weight loss because of inevitable stomal widening. In 1981 vertical gastroplasty was introduced and again initial methods resulted in breakdown of staples and stomal enlargement and were soon modified by the addition of a band or silastic ring around the stoma to support the outlet and prevent it from stretching. This modification was known as vertical banded gastroplasty (VBG) and is what is what is used today.

VBG can be carried out as open surgery or laparoscopically. The first laparoscopic VBG was performed in 1993 and is now more commonly performed because of the reduction in complications associated with wounds such as infection and incisional hernias.

Gastroplasties are becoming less widely used now with the introduction of the adjustable gastric banding technique which is simpler and avoids incision of the stomach and the use of staples. World-wide VBGs comprise around 5% of all weight loss operations, thus making it the third most common surgery for obesity. In Australia however, it is performed with much less frequency due to it's high long term re-operation rate of about 20%. In Australia the most common procedure is laparoscopic adjustable gastric banding (LABG) which is carried out in more than 90% of cases.

Weight-loss surgery is performed to aid morbidly obese patients lose weight, as their weight often impacts significantly on their health and state of mental well being. Often they will also be suffering from other life threatening or debilitating illnesses such as heart disease, diabetes, depression, sleep apnoea and osteoarthritis.

The suitability of a patient for gastroplasty is essentially the same as for all weight-loss surgeries. Certain guidelines are set by the National institutes of health (NIH) and the National Health and Medical Research Council (NHMRC) which outline selection criteria that must be taken into consideration before a doctor can recommend weight loss surgery:

Weight greater than 45kg above ideal body weight for sex, and height. Body mass index (BMI) greater than 40 by itself or greater than 35 if there is an associated obesity illness, such as diabetes or heart diseaseSeveral previous attempts already made using other non-surgical weight loss techniques Aged between 18-65 yearsHas been at current weight for 3-5 yearsHas obesity related health problems  No drug and alcohol dependency problems or major psychiatric illnessCapable of tolerating surgeryunderstands the risks and long term commitment associated with the surgery. Patient motivation and willingness to commit to behavioural and lifestyle changes following surgery and is committed to long term follow up.Is not pregnant and not planning a pregnancy within the first two years after surgery

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The formula for calculating your body mass index is:
BMI = weight (kilograms) / (height (metres) * height (metres))

For example:
A man who weighs 85 kilograms and is 1.8 metres tall would have a BMI of
BMI = 85 / (1.8 * 1.8)
BMI = 85 / 3.24
BMI = 26.2

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Click here to calculate your BMI.

There are some exceptions to this and patients as young as 12 have been offered surgery. Sometimes a lower BMI of 30-35 is accepted if a patient is also suffering from hypertension, diabetes mellitus, hyperlipidema, severe osteoarthritis or sleep apnoea.

Gastroplasty is generally a quick and safe procedure in comparison to many of the other weight loss operations and now with laparoscopic method available also reduces the risk of certain complications. It also has a very low mortality rate in comparison to other surgeries. The procedure is reversible as the digestive tract is left intact and there is also less risk of infection.

Because gastroplasty does not involve alterations of the anatomy of the gastrointestinal tract there are no effects of such as those seen in malabsorption surgeries. Nutritional deficiencies such as anaemia are uncommon with less than 3% of those undergoing VGB experiencing deficiencies as opposed to 17% patients with gastric bypass. In addition, maintaining a normal anatomy also allows passage of an endoscope if necessary later on.

As with most bariatric surgeries the resulting weight loss can help reduce the effects of co-morbidities such as cardiovascular disease, hypertension and diabetes. One study found it reduced the risk of cancer incidence.

VBG is losing favour over other forms of bariatric surgery, mainly because it has been the least successful in maintaining weight loss long-term. It is also the procedure which produces less weight loss initially. VBG patients can lose about 40-50% of their excess body weight over the first two years but this drops to 20% after three years. Several studies have found that patients undergoing gastroplasty lose around 10kg less than those undergoing with Roux-en-Y Gastric Bypass (RYGB) at 12 and 36 months post surgery with the average weight loss around 32 kg compared to 42kg for gastric bypass. The main contributing factors to late weight gain are expansion of the pouch, staple line breakdown and migration of the band supporting the outlet.

Following surgery patients are required to adhere to a very strict diet and must follow advice on how to eat food to avoid problems. Reversal of gastroplasty is carried out in about 4% of patients because of food intolerance. Vomiting and severe discomfort is experienced if food is not properly chewed or if food is eaten too quickly.

Maladaptive eating behaviours can occur which also contributes to weight gain. One such behaviour is the ‘soft calorie syndrome’ where patients tend to ingest ice-cream and high calorie soft drinks which easily pass through the narrow outlet from the pouch. Highly refined foods also tend to be easier to eat while high fibre foods such as fruit and vegetables are very difficult so many patients slowly regain weight lost after surgery by consuming more calorie rich foods.

VBG is not adjustable like gastric banding, however it can be reversed or converted to a gastric bypass.

Complications

The most common complications associated with VBG are obstruction, leakage from the stomach, outlet stenosis, pouch dilatation, ulcers, incisional hernia, fistulas, wound infections, band erosion, staple line disruption and bleeding from the staple line and rarely, pulmonary complications.

Stenosis may occur from infection of the material supporting the stoma or a reaction of the scar tissue around it. It may manifest as deterioration of ability to eat solid food and regurgitation. Heartburn is a consequence of this and patient may have to resort to a liquid diet.
Leakage from the stomach usually manifests as tachycardia with severe abdominal pain and a subsequent increase in body temperature. Patients may experience difficulty breathing and pain in the left shoulder.

Thromboembolic disease in not common but can be life threatening. To avoid this, patients should be encouraged to get up and walk around early on after surgery. Other preventative measures that may be taken include administration of low dose heparin for the duration of the hospital stay.

Mortality associated with VBG is very low (0-1.7%) with pulmonary embolus being most common cause of death. Mortality is also related to the experience of the surgeon.

Generally, laparoscopic procedures require a shorter recovery time and have a reduced incidence of wound infection and incisional hernias compared with open surgery. However, it appears that the re-operation rate is higher with laparoscopic procedures.

Long term complications

A ten year follow-up study found that the most common long term complications were, staple line disruption, mechanical or functional stomal obstruction and maladaptive eating behaviours. A high incidence of persisent vomiting, heartburn and dumping is also common. Most importantly only 26% of patients maintained weight loss after ten years.

Late complications that require re-operation include the onset of gastroesophageal reflux, staple line fistula, food intolerance, pouch enlargement and incisional hernias.

Evaluating a patient who is interested in bariatric surgery is complex and often involves collaborations between the surgeon, a nutritional specialist and a psychologist. A patient’s medical history and a full physical examination is conducted in order to identify any risk factors such as hypertension, type 2 diabetes and hypoventilation syndrome. A dietician is also involved in assessing a candidate’s relationship with food and eating behaviours. Patients need to be well informed of all aspects of the procedure including the risks, benefits, side effects, and expected weight loss. Particular emphasis must be placed on the importance of making permanent dietary and lifestyle changes to ensure long-term the success of the surgery and to reduce the chance of weight gain and other complications. Patient motivation and willingness to adhere to all post-operative dietary recommendations is the key to ensuring long term successful weight loss.

Surgeons can only do so much and the rest is up to the patient. They must be willing to modify their eating habits and understand the effects on eating techniques following surgery.

VBG is performed under general anaesthetic and takes about one hour. The procedure involves making a hole in both layers of the stomach with a circular stapling device to create an opening through which a stapler could be passed. The stomach is then divided using staples to create a small pouch closest to the oesophagus. The end of the pouch is narrowed to create a small outlet of about 10-12mm width which leads into the remainder of the stomach. This outlet is reinforced with a silastic ring which prevents it from stretching.

Following gastroplasty surgery, patients will feel full after eating only small amount of food and also stay full longer thus leading to a drastic reduction in calorie-intake. Most weight loss occurs in the first six-months to a year following surgery. Further success is dependant on a patient’s compliance with a strict diet and exercise regime.

Usually patients can be discharged from the hospital 3-4 days after surgery. If a laparoscopic procedure was performed then they may be able to leave even earlier.

In order to prevent discomfort and complications patients are required to follow a very strict diet, especially in the weeks after surgery. It is recommended that only liquids are ingested in the first 1-2 weeks post surgery followed by soft pureed food for three more weeks before commencing on solids. Patients are advised on the correct technique when eating such that obstruction does not occur.

Those adhering to strict follow-up and regular monitoring with their surgeon and dietician are more likely to have successful outcomes. A strict eating plan and exercise regime should be made early on and commenced immediately following discharge.

Eating and drinking at the same time should be avoided as food will be washed down into the distal stomach and the feeling of fullness will not be achieved.

Ultimately it is up to the patient to ensure long term success of their surgery. They must be willing and motivated to comply to all dietary and lifestyle changes recommended. Ongoing social and psychological support will be necessary in achieving this.

For more information on obesity, health and social issues, and methods of weight loss, as well as some useful tools, see Obesity and Weight Loss.  Wright AJ, Sudan R and Forse AR. A clinical guide in the management of overweight and obese children and adults. In: Surgical Treatment of Obesity. Ch7 p123-139Bult MJF, van Dalen T and Muller AF. Surgical treatment of obesity. European Journal of Endocrinology. 2008; 158(2); p. 135-145.Schweitzer M, Lidor A and Magnuson T. Bariatric surgery. In: Health and treatment strategies in obesity. Advances in psychosomatic medicine. Vol 27; p. 53-60. Editor: Vaidya V. Switzerland; S. Karger AG. 2006.Jamieson AC. Vertical banded gastroplasty. In: Surgical management of obesity. p.167-176. Editors: Buchwald H, Cowan GSM and Pories WJ. Philadelphia: Elsevier Saunders. 2007.Maggard MA, Shugarman LR, Suttorp S,  Maglione M et al. Meta-analysis: surgical treatment of obesity. Annals of Internal Medicine 2005; 142(7); p. 547Champion JK and Williams M. Laparoscopic vertical banded gastroplasty. In: Surgical management of obesity. p.177-184. Editors: Buchwald H, Cowan GSM and Pories WJ. Philadelphia: Elsevier Saunders. 2007.North-eastern Weight Loss Surgery. Obesity Surgery Melbourne. Vertical banded gastroplasty. Available online: http://melbourneobesitysurgery.com.au/vertical_gastroplasty.html. Accessed 20 March 2008.National Health and Medical Research Council. (2003). Clinical practice guidelines for the management of overweight and obesity in Australia [update 19th March 2004] Commonwealth of Australia, Department of Health and Ageing.
Available online: www.obesityguidelines.gov.auUS National Institutes of Health. Clinical guidelines on the identification,evaluation and treatment of overweight and obesity in adults: executive summary. Expert Panel on the Identification, Evaluation and Treatment of Overweight in Adults. Am J Clin Nutr; 1998; 68(4); p. 899–917.Mason E. Development and future of gastroplasties for morbid obesity. Archives in Surgery; April 2003; 38Colquitt, J. Clegg, A. Loveman, E. Royle, P. Sidhu, M. (2005). Surgery for morbid obesity. Cochrane clinical review. Available online: [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003641/frame.htmlBalsiger BM, Poggio JL, Mai J, Kelly KA and Sarr MG. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity. Journal of Gastro-intestinal Surgery 2000; 4(6); p. 598-605.

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Joint pain (Arthralgia)

Joint pain (arthralgia) is an extremely common symptom which most people will experience at some point in their lives. Joint pain has many different causes, ranging from local injury to the joint to whole-body illnesses which include joint pain as one part of the disease.

Joint pain can be caused by a number of different mechanisms. Joint pain may be caused by damage to a structure within the joint itself (such as the joint surface) or by damage to a structure near the joint, such as a tendon. Joint pain may be due to local damage within the joint, or may be just one part of a systemic (whole-body) disease process. One of the most important distinctions to make is whether joint pain is caused by inflammation of the joint (an immune response involving swelling, redness and warmth) or whether there is joint pain without inflammation.

Inflammatory joint disorders are characterised by:

Swelling, redness, warmth and pain; Systemic (whole-body) symptoms, such as fatigue, fever or weight loss; Marked morning stiffness, or stiffness that worsens with long periods of rest and inactivity, and is improved with movement or anti-inflammatory drugs. Common inflammatory joint disorders include: Rheumatoid arthritis; Seronegative spondyloarthropathies, including ankylosing spondylitis and psoriatic arthritis; Infectious arthritis: bacterial (septic arthritis), viral (e.g. Ross River Virus) or other; Reactive (post-infectious) arthritis, e.g. Reiter's syndrome; Inflammatory osteoarthritis; Crystal arthropathies: e.g. gout or pseudogout; Systemic rheumatic illnesses causing arthritis: e.g. systemic lupus erythematosus, Behcet's disease; Other systemic illnesses, e.g. sarcoidosis, acromegaly.

Non-inflammatory joint disorders are characterised by:

Pain without swelling or warmth; Absence of systemic symptoms such as fever or weight loss; Minimal morning stiffness which is intermittent, lasts less than 60 minutes; and Stiffness which is made worse, not improved, by activity. Common non-inflammatory joint disorders include: Trauma, e.g. tears to muscles, tendons or cartilage around the joint; or Osteoarthritis. Some people may also experience joint pain as a symptom of depression.

Any unexplained joint pain which is causing you trouble should be investigated. In particular, there are certain 'warning signs' which need quick review by a healthcare professional. These include:

Joint pain with fever, not caused by the flu; Involuntary weight loss; or Unexplained joint pain which lasts longer than 3 days, or is severe.

Your healthcare professional will try to determine the likely cause of your joint pain by asking you a number of questions.

What does the pain feel like? Is it deep, on the surface, in one spot or all over? Which joints are painful? Some types of arthritis have particular patterns of joint involvement, which may help in making a diagnosis. Are there any associated joint symptoms? For example, does the joint ever feel like it is 'giving way' under you, or 'sticking'? Have you ever injured or had surgery to the joint? How long has the pain been present for? Pain which develops quickly is likely to be due to a different cause than pain which has been present for weeks. Do you feel generally well, or is the joint pain associated with tiredness, weight loss or fever? Has anyone else in your family had problems with joints? Family members with gout, rheumatoid arthritis, or other types of arthritis such as psoriatic arthritis are particularly important, as these conditions may be inherited. How is the joint pain affecting your life and your ability to manage daily tasks?

Your healthcare professional will then need to examine the joint(s) which are involved. This usually involves a careful inspection of the joint to look for swelling, redness, scars or deformity, followed by assessment of the range of movement that is possible. Special manoeuvres may also be needed to identify particular causes of joint pain.

If the likely cause of your joint pain has not been established after asking you questions and examining the joint, your healthcare professional may wish to arrange some tests.

Blood tests

Full blood picture: a raised white cell count may indicate inflammation or infection; ESR or CRP: raised levels of these tests may suggest an inflammatory cause for the joint pain; Uric acid: gouty arthritis is caused by excess levels of uric acid in the blood. In an acute attack, however, the level of uric acid in the blood is not always raised. Viral serology: if your health professional suspects that your arthritis may be caused by a virus such as Epstein Barr virus, parvovirus B19, hepatitis B or hepatitis C, he or she may order tests to look for these viruses in the blood; Special blood tests may also be done for some immune proteins such as rheumatoid factor or antinuclear antibodies (ANA). Presence of these proteins in the blood may be associated with auto-immune diseases such as rheumatoid arthritis or systemic lupus erythematosus. However, they may also be present in normal people.

Joint fluid analysis

This involves using a needle to take a sample of the fluid within a swollen joint. The fluid can be examined to look for presence of inflammation, bacteria, or crystals associated with diseases such as gout. Your health professional may order joint fluid analysis if he or she particularly suspects that you have a bacterial infection or crystals (gout or pseudogout) in the joint.

Imaging

Plain x-rays can be useful in the diagnosis of some joint disorders such as trauma or osteoarthritis. In inflammatory joint disorders, it may take much longer for the joint changes to be seen on plain x-ray. In these cases your health professional may arrange for you to have an ultrasound or MRI scan of the joint.

The treatment for your joint pain will depend on the cause. The best sort of analgesia (pain relief) for your joint pain is also partially dependent on the cause - inflammatory joint pain is likely to respond well to corticosteroids or non-steroidal anti-inflammatory drugs such as ibuprofen, whereas non-inflammatory joint pain is better managed with paracetamol. Other techniques to manage joint pain include physiotherapy.

It is not possible to prevent the development of many diseases which cause joint pain, including rheumatoid arthritis and other auto-immune causes of joint pain. Osteoarthritis is a common cause of joint pain which is thought to result from 'wear and tear' on a joint over a number of years. Some simple lifestyle changes can help reduce this wear and tear, including weight loss, wearing comfortable shoes, or learning safe techniques for lifting, and these may reduce the likelihood of developing osteoarthritis later in life.

Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison's Principles of Internal Medicine. 16th Edition. McGraw-Hill. 2005. Pinals, RS. 'Evaluation of the adult with polyarticular pain' [online]. UpToDate.com. 2006. Available at URL: http://www.uptodate.com (last accessed: 2/9/06) Solomon L, Warwick DJ, Nayagam S. Apley's Concise System of Orthopaedics and Fractures. London, Hodder Headline Group, 2005.

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Blood Pressure Calculator

Normal
Your blood pressure should be rechecked within 2 years or earlier depending on your risk of developing cardiovascular disease. Your General Practitioner can advise you about this risk and also on lifestyle risk reduction.High-Normal
Your blood pressure is elevated. It should be rechecked within 12 months or earlier depending on your risk of developing cardiovascular disease. Your General Practitioner can advise you about this risk and also on lifestyle risk reduction.Grade 1 (mild) Hypertension
Your blood pressure is elevated. It should be confirmed within 2 months. Your General Practitioner should advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Grade 2 (moderate) Hypertension
Your blood pressure is elevated. It should be confirmed within 1 month and you may also need to see a specialist in this time. Your General Practitioner can advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Grade 3 (severe) Hypertension
Your blood pressure is elevated. It should be confirmed within 1 week and you may also need to see a specialist in this time. Your General Practitioner can advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Isolated systolic hypertension
Your systolic blood pressure is elevated. Depending on the level it needs to be confirmed within a certain time (140-159mmHg - 2 months; 160-179mmHg - 1 month; >180mmHg - 1-7 days).You may also need to see a specialist. Your General Practitioner can advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Isolated systolic hypertension with widened pulse pressure
Your blood pressure is elevated. It should be confirmed within 1 week and you may also need to see a specialist in this time. Your General Practitioner can advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Hypotension
Your blood pressure is lower than normal. Your General Practitioner will ask you about symptoms that you may be experiencing and determine if you require treatment or further investigation.

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For more information on blood, blood types, blood tests, and blood donation and transfusion, see Blood.

For more information on high blood pressure, including investigations and treatments, as well as some useful animations, videos and tools, see Hypertension (High Blood Pressure).  

Created: 24/2/2010


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Female Condom

The female condom is a transparent, loose fitting, polyurethane sheath inserted into the vagina prior to sexual intercourse (either vaginal or oral). A female condom is 17 cm long, and has a flexible ring at each end. One end of the condom is closed and this end is inserted into the vagina to capture male semen during heterosexual intercourse. The other end of the condom is open, and this end remains outside the woman's vagina during sexual activity, partially covering her external genitalia. The woman's partner inserts their penis or tongue into the open end of the condom during vaginal or oral sexual activity.

Like the male condom, the female condom is a barrier method, that is, it creates a barrier between the woman's vagina and her partner's penis or mouth, which prevents the mixing of fluids during sexual activity. In doing so, the female condom provides users with a high degree of protection against pregnancy and sexually transmitted infection (STI) spread via genital fluids (e.g. HIV). As the female condom provides greater anatomical coverage than the male condom (it covers much of the woman's external genitalia in addition to the penis and vagina), it may also provide a higher degree of protection than male condoms against STIs spread through skin contact (e.g. herpes).

Female condoms have been available in Europe and the US since 1992, and have been marketed under various names, including Femidom and Reality. They first became available in Australia in 2000, where they are sold as the Female Condom.

The female condom was developed as an alternative to male condoms, in recognition that the decision to use male condoms was highly dependent on the willingness of the male sexual partner as the male condom is fitted onto the male sexual organ.

As the female condom is applied to the female genital organs, it was hypothesised that women would find it easier to initiate the use of a female condom than they would with a male condom. Because of this, it was thought that the female condom would empower women, who often lack decision making power and control in sexual relationships, to take greater control their sexual health. The female condom has been widely labelled the only "female initiated" method of preventing STIs.

The female condom works by providing a barrier which sexual fluids cannot penetrate and thus protects against both pregnancy and STIs. In terms of contraception, preventing semen and sperm from entering the vagina prevents pregnancy. Sperm cannot fertilise an egg if they are trapped in a condom.

In terms of STIs, the female condom prevents the male partner being exposed to the female partner's vaginal fluids and the female partner being exposed to the male partner's semen during heterosexual intercourse. Thus it prevents the spread of STIs which are transmitted via sexual fluids (e.g. chlamydia).

The female condom also covers some of the woman's external genitalia (e.g. the vulva, labia), and thus should provide a greater degree of protection against STIs spread through skin contact, than the male condom. During oral sex, the female condom also prevents contact between a woman's vaginal fluids and her partner's mouth.

Female condoms are suitable for use during vaginal and oral sex, but not during anal sex.

In order to protect against pregnancy, female condoms should be used at every act of penetrative vaginal intercourse when another effective contraceptive is not being used.

As an STI prevention device, female condoms should be used both for oral and penetrative vaginal sex, particularly when the partner's STI status is unknown (most typically with casual partners, but also with some regular partners). The condom should be inserted before any contact between partners' genital areas occurs.

Despite their efficacy, female condoms are not widely used and account for only 0.2% of the global condom supply. They are still not readily available in many countries and remain much more expensive than male condoms. In 2008, 34.7 million female condoms were sold worldwide.

Like male condoms, female condoms provide a barrier which is impenetrable by sexual fluids. As female condoms provide greater anatomical coverage than male condoms (they also cover much of the woman's external genitalia), they are, at least in theory, even more effective in preventing the transmission of STIs than male condoms. However while evidence is somewhat limited, it suggests that female condoms are no more effective than male condoms in practice. This appears to be because they are more difficult to use and are therefore subject to higher rates of mechanical failure (e.g. slippage, breakage).

Effectiveness in preventing pregnancy

In relation to contraceptive efficacy, the World Health Organisation reports an annual incidence of unwanted pregnancy of 5%, when female condoms are used correctly and consistently. This compares to an annual incidence of 3% with correct and consistent use of male condoms.

Effectiveness in preventing STIs

In relation to STI prevention, studies investigating the effectiveness of female condoms have examined rates of breakage and slippage, semen exposure and new cases of STI amongst female condom users. A study examining new cases of STI in female users of male and female condoms found no significant differences in incident STIs between the groups. In terms of mechanical failure, research indicates that female condoms are less likely to break but more likely to slip during sexual intercourse, compared to male condoms (0.1% breakage of female condoms vs 3.1% breakage of male condoms; and 5.6% slipping in female condoms vs 1.1% slipping in male condoms). However, a study investigating semen exposure reported no difference in the proportion of vaginal fluid samples which had been exposed to semen, between users of male and female condoms. This is despite much higher rates of mechanical failure while using female condoms (34% compared to 9% for male condoms).

Effectiveness in empowering women to negotiate condom use

In terms of their ability to empower women by enabling female initiation of barrier method use, evidence to date suggests that women are no more able to initiate the use of a female condom without their partner's consent, than they are a male condom. That the female condom is applied to the female genitalia does not negate the fact that many women lack the power to insist on its use, nor does it do away with the discrimination and stigma a woman might experience for carrying a condom (e.g. women have reported being labelled as promiscuous for carrying condoms).

Some argue that promoters of female condoms have failed to consider the widespread impact of discriminatory gender relations and, that to fulfil its STI and pregnancy prevention potential, the female condom needs to also be promoted amongst men, as a device which can increase their sexual pleasure.

Many women find inserting a female condom difficult at first, but research indicates that insertion becomes easier and less mistakes are made with practice. It is therefore recommended that women who wish to use a female condom, practice inserting them several times in a private, comfortable environment, prior to using them during sexual intercourse. It may also be necessary for women to use female condoms during several sexual encounters before they become used to the feel and appearance of female condom.

Women who wish to use a female condom should familiarise themselves with the following instructions about the application of female condoms:

Open the packet carefully and remove the condom. Rub both sides to distribute the lubricant evenly across the condom.Choose a comfortable position for insertion (e.g. squatting, raising one leg or lying down).While holding the condom at the closed end, grasp the flexible inner ring and squeeze it with the thumb and forefinger so it becomes long and narrow.With your free hand, hold the outer lips of the vagina open and gently insert the ring up into the vagina, using the thumb and forefinger.Place your index finger inside the ring and push the condom up the vagina as far as possible, until it is above your pubic bone. (The pubic bone can be felt as a large lump by putting your finger inside your vagina and moving it up and to the front.) Once the female condom is properly inserted, the pubic bone will hold it in place and prevent it from slipping out of the vagina during intercourse.The outer ring should stay outside of the vagina.The female condom should not create any discomfort, and once properly inserted, the woman should not be able to feel it.

When having sexual intercourse using a female condom, women should:

Guide the penis with their hand into the open end of the condom, making sure it goes into the condom and not to the side. As the condom is lubricated and slippery it is easy for the penis to slip between the condom and the vagina if the penis is not carefully guided;Ensure there is enough lubricant so the condom stays in place during sex. If the condom is pulled out or pushed in, there is not enough lubricant. You can add more lubricant to either the inside of the condom or the outside of the penis;To remove the condom, twist the outer ring then pull it out. Be careful not to let the semen leak out. If the woman was not upright during intercourse, she should remove the condom from her vagina before standing up, to prevent semen leaking out;Wrap the condom in a tissue and throw it in the bin. Do not flush it down the toilet.

In addition it is important that female condom users are aware that:

male and female condoms should not be used together; andthe female condom should only be used once.

If the condom breaks during intercourse, the penis should be withdrawn immediately. If the sexual partners still wish to continue having sex, a new condom should be applied prior to any further genital contact.

As a precautionary measure against unwanted pregnancy, women who experience condom breakage should visit their general practitioner and obtain a prescription for an emergency contraception pill. Emergency contraceptives can be used up to 120 hours after intercourse, to reduce the risk of pregnancy.

Both male and female partners should also test for a range of STIs if they experience condom breakage and are unsure of their partner's STI status. Many STIs are easily treated with antibiotics once detected. However, as many STIs remain asymptomatic for extended periods of time, leaving them untreated can lead to infertility and other complications. For more information see STI.

STI prevention

The female condom is one of only two biomedical devices (the other being the male condom) which provides a high level of protection against a range of STIs in sexually active individuals. Condoms thus enable individuals who choose to be sexually active, and particularly those who choose to be sexually active with multiple partners, to reduce the risk of adverse health effects associated with sexual activity. They offer a degree of sexual freedom to individuals living in a world characterised by numerous health risks stemming from sexual activity.

Appropriate for temporary or permanent contraceptive use

As female condoms are applied immediately prior to sexual intercourse, an individual does not need to plan condom use in advance as they do for many other methods of contraceptives (e.g. hormonal contraceptive pills must be taken for extended periods). When used consistently and correctly, female condoms provide a high level of protection against unwanted pregnancy.

Made from polyurethane

Female condoms are made from polyurethane - an odourless, soft material, which has a more natural feel than the latex from which most male condoms are made. This is largely because it is thin and conducts heat more efficiently, and thus increases sensitivity.

Heat resistant

Changes in temperature or humidity do not affect the polyurethane from which female condoms are made. Male condoms on the other hand are sensitive to heat and must be stored at room temperature.

Less likely to split

Female condoms are less likely to break than male latex condoms.

Non-allergic

Unlike latex, the polyurethane with which female condoms are made does not cause allergies, thus female condoms are suitable for people with latex allergies.

Lubrication

Female condoms can be used with both oil and water based lubricants, unlike male latex condoms which must be used only with water-based lubricants.

Greater anatomical coverage

The outer ring of the female condom gives protection to the female's external genitalia. The female condom therefore provides better coverage and protection against STIs transmitted through skin contact than a male condom.

Offers flexibility in the timing of insertion and removal

The female condom can be inserted up to eight hours before intercourse and does not need to be removed immediately after male ejaculation. This gives greater sexual spontaneity than male condoms. In addition, unlike the male condom, use of the female condom is not contingent on the male partner achieving an erection.

Greater female control

As the female condom is applied to the woman's genital organs, it is theorised that it provides women with a greater sense of control over their sexual health than the male condom, which is applied to the male genital organs. While evidence suggests that women are no more able to enforce the use of female condoms than male condoms, there is also evidence that women do find it empowering to have access to a product which they wear.

Despite the many advantages of female condoms compared to male condoms, they remain a much less popular method of either contraceptive or STI protection than male condoms. Some of the disadvantages of female condoms which may create barriers to their use are discussed below.

User satisfaction

User satisfaction with female condoms, at least amongst some groups of women is low, and considerably lower than satisfaction with male condoms. For example, one study reported that only 11% of women reported that sex with the female condom felt "good" or "very good". Women also reported low levels of satisfaction with the female condom amongst their partners.

Appearance

The female condom is large and some women find its overall appearance off-putting. In addition, once inserted, the outer ring is visible outside the vagina, which can make some women and their partners feel uncomfortable.

Noise

Female condoms typically make a rustling noise during intercourse.

Difficult to use

Users of female condoms report far greater incidence of mechanical difficulties (breaking, slipping) than do users of male condoms. Most health practitioners acknowledge that inserting the female condom is difficult and requires practice.

Failure rate

While the polyurethane from which female condoms are made is impenetrable, there is the possibility that the condom will slip up inside the vagina or the penis will enter the vagina and not the condom, and lead to condom failure.

Female condoms are much more likely to slip out of place during sexual intercourse than male condoms (e.g. one study reported 5.6% rate of slippage for female condoms compared to 1.1% for male condoms). Despite the higher rate of slippage, research indicates that the risk of semen exposure is comparable between male and female condoms.

Expense and availability

Female condoms are much more expensive than male condoms and, in Australia are available only from specialty outlets like pharmacies (and not supermarkets and petrol stations). They can also be expensive compared to male condoms. However, some student services do provide free female condoms.

Female condoms are available from family planning services, community health centres and pharmacies. Some student services also distribute free female condoms.

In 2005 a new female condom called FC2 was released by the manufacturers of the female condom. While it has a similar design to the original version of the device, FC2 is made from a material called nitrile. This makes it cheaper to produce than the polyurethane version and also eliminates the noise associated with polyurethane condoms. Female condoms made from latex are also being developed, which has the potential to further reduce costs.

For more information on different types of contraception, female anatomy and related health issues, see Contraception.Gollub E, Warren M. The female condom: A guide for planning and programming, World Health Organisation. 2005. [cited 2009, March 15] available from: http://www.who.int/reproductive-health/publications/RHR_00_8/PDF/female_condom_guide_planning_programming.pdfUnited States Department  of Veteran's Affairs. Tips for using condoms and dental dams. 2008. [cited 2009, March 15] available from: http://www.hiv.va.gov/vahiv?page=sex-condomtips Padian, N.S. Buve, A. Balkus, J. et al, Biomedical Interventions to prevent HIV: evidence, challenges and new ways forward The Lancet. 2008;372:585-99.McNamee K. The female condom. Aust Fam Physician. 2000;29(6):555-7.Valappil, T. Kelaghan, J. Macaluso, M. Male and Female Condom failure among women at high risk of sexually transmitted diseases. Sex Transm Dis. 2005;32(1):35-43.Mantell, J.E. Dworkin, S.L. Exner, T.M. et al The Promises and Limitations of Female-initiated methods of HIV/STI prevention. Soc Sci & Med. 2006;63:1998-2009.Family Planning New South Wales. The Female Condom. 2009. [cited 2009, March 15] available from: http://www.fpnsw.org.au/sex-matters/factsheets/52.html Anonymous. The female condom: Still an underused prevention tool. [Editorial] Lancet Infect Dis. 2008;8(6):343.Avert. The Female Condom. 2008. [cited 2009, March 15] available from: http://www.avert.org/femcond.htm Macaluso, M. Blackwell, R. Jamieson, D.J. Efficacy of the Male Latex Condom as Barriers to Semen during Intercourse: a randomised clinical trial. Am J Epidemiol. 2007. DOI: 10.1093/aje/kwm046. [cited 2009, March 15] available from:  http://aje.oxfordjournals.org/cgi/content/abstract/kwm046v1 French. P.P. Latka, M. Gollub, E. et al. Use effectiveness of female vs male condoms in preventing sexually transmitted disease in women. Sex Transm Dis. 2003;30(5):433-9.Attorney General's Department. National Sexually Transmissible Infections Strategy 2005-08. Commonwealth of Australia. [cited 2009, March 15] available from:  http://www.health.gov.au/internet/main/publishing.nsf/Content/0333DF52D0E2F3EDCA25702A0025132F/$File/sti_strategy.pdf Kulczycki, A. Kim, D. Duerr, A. et al. The acceptability of the Female and Male Condom: a randomised crossover trial. Perspect Sex Reprod Health. 2004;36(3):114-9.

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Lumbar Puncture (Cerebrospinal Fluid Examination)

A lumbar puncture is a procedure that is used to examine the cerebrospinal fluid (CSF). The cerebrospinal fluid is the fluid which circulates around the brain and membranes around the brain and spinal cord (the meninges). It is mainly used in aiding diagnoses pertaining to infection, inflammatory diseases and traumatic injuries. It can also be used therapeutically and for anaesthesia, however this document is mainly concerned with the investigative use of a lumbar puncture.

To begin with the procedure is usually carefully explained to the patient, including the risks and benefits. In experienced hands, a lumbar puncture is a relatively safe procedure. Proper positioning of the patient is extremely important. The patient is asked to lie on their side, with their back toward the examiner and then curl into a ball. This involves the patient flexing their neck and lower spine, whilst drawing up their thighs toward their chest. The shoulders and pelvis should be vertically aligned without forward or backward tilt. In approximately 94% of individuals the spinal cord terminates at the level of the L1 vertebrae. In the further 6% of individuals the spinal cord can extend to the L2-L3 interspace. Therefore a lumbar puncture is generally performed at or below the L3-L4 interspace. As a general anatomical rule, the line drawn between the posterior iliac crests often corresponds closely to the level of L3-L4. The interspace is selected after palpation of the spinous processes at each lumbar level.Once the area for needle insertion has been ascertained, the examiner puts on a mask and sterile gloves - this decreases the risk of infection. The skin is then cleansed with alcohol and usually an iodine based disinfectant and the area is draped with a sterile cloth. A local anaesthetic, commonly 1% lignocaine, is injected into the subcutaneous area - this should be ideally done at least 5 minutes prior to insertion of the lumbar puncture needle.The lumbar puncture needle is typically a 20 - 22 gauge needle and it is inserted into the target area and slowly advanced. The bevel of the needle is maintained in a horizontal position (with the flat portion of the bevel pointing up) and it should be parralel to the direction of the dural fibers. In most cases the needle is advanced 4 - 5cm before the subarachnoid space is reached - this is characteristically recognized by a sudden decrease in resistance and sometimes a 'popping' sound may be heard. Once a subarachnoid space has been reached, a manometer can be attached to the needle to record the opening pressure. Fluid is then usually obtained for collection. Fifteen millilitres of CSF is usually sufficient for a sample. The fluid is then taken and may be analysed for a number of parameters (according to the clinical presentation) including: cell count with differential protein and glucose concentrations culture - bacterial, fungal, mycobacterial and viral smears - gram stains and acid-fast bacilli smear antigen tests and serology (e.g. cryptococcal antigen, latex agglutination, limulus lusate tests) PCR (polymerase chain reaction) tests to amplify DNA or RNA of micro-organisms antibody tests immunoelectrophoresis cytology or cell studiesSome normal values for CSF parametes are as follows: Glucose 2.22-3.89mmol/L Lactate 1-2mmol/L Protein 0.15-5g/L Red Blood Cells 0 IgG 0.009-0.057g/LThe minor risks and complications associated with a lumbar puncture include backache, post lumbar puncture headache, radicular pain and numbness. Major complications that rarely occur include infection, haemorrhage, damage to the spinal cord or nerve roots and herniation of cerebral tissue in patients with pre-existing increased intracranial pressure.



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CT Scan or CAT scan (Computed Tomography Imaging)

Computed Tomography Imaging known as a CT scan (or CAT scan) is a particular type of x-ray that uses multiple x-ray beams at different angles to build up a cross section of the body's organs and tissues.

CT scans can show several types of tissue with great clarity such as bone, soft tissue and blood vessels and allows easy differentiation between soft tissue structures, which greatly improves on the conventional x-ray. CT scans can detect and determine the exact size and location of anatomical abnormalities such as tumours, lesions, blood clots and blood vessel defects and bone defects. The images produced are generally of cross-sectional nature, with multiple scans creating the ability to produce 3-D images of internal structures.

Computed Tomography Imaging works on the same basis of an x-ray. As the x-ray beams pass through the body, they are absorbed at different levels and a profile is created of x-rays beams of different strengths. These are recorded on film as an image or in the case of an x-ray, resembling a shadow. The use of a computer in CT scanning is what differs from a conventional x-ray. A CT scanner consists of a table on which the patient lies which moves in through the ring shaped scanner. A moveable ring located is on the edge of the scanner which contains the x-ray tube and its associated detectors. A CT scan involves the movable ring revolving around the patient with fine fan of x-ray beams being passed through the body from all angles into their associated detectors, with the information from each detector relating to a particular part of the body. All this information from the detectors must be compiled into a detailed image of the particular slice of the body by the computer. Every time the movable ring makes a 360 degree rotation, a slice has been acquired. These slices give such detailed images of the internal structures of the body that they have become widely used in radiology, in both the diagnosis of diseases, checking of bodily structures such as the brain, heart, liver, lungs and kidneys and also in trauma to check for injury.

Preparation for a CT scan is similar to x-rays and MRI scans. Most radiology clinics provide patients with a hospital gown, but otherwise all jewellery and items such as hats, belts, clips, and glasses must be removed as some objects have a detrimental effect on the image when scanned. In some cases contrast agents are administered to image particular tissues more effectively. Many contrasts agents do contain iodine, which can provoke an allergic reaction in some patients. If you have an allergy to iodine or any other allergies, notify the nurse, technician or radiologists before the administration of the contrast agent. If you suspect you may be pregnant or you are pregnant, you must notify your doctor before the CT scan as this procedure does involve radiation and can be dangerous to a developing foetus. A CT scan is very similar to a MRI scan.

You will be asked to lie on the table in a still position and the table will move into the tunnel. During the scan, the table will move a small distance every few seconds to reposition you for the next scan. During the scanning, the machine may make buzzing or click sounds as it moves. You will be alone in the scanning room, but the radiologist conducting the scan will be able to see you through a window into the room and communicate with you via intercom. The scan can last from 30-90 minutes, during which you will be asked to lie very still in the scanner which for some can cause anxiety or claustrophobia. If you suffer from a fear of small spaces (claustrophobia), inform your doctor and the radiologists and a sedative can be administered in appropriate conditions. After the scan, the details of the results may be shared by the radiologist or referred back to your doctor. Your day can continue as normal however it is recommended if you were given a contrast agent to drink water to flush your body of the agent.

Risks associated with CT scans can be associated with an allergic reaction to the contrast agent, which can lead to an allergic reaction such as a rash or nausea to more extreme and rare cases of sudden shock. An extreme reaction is very rare as the patient is constantly monitored and medical histories examined. If you do have an allergy particularly to iodine or to other substances inform your doctor, radiologist, technician or nurse. As this is a procedure that uses x-ray beams, there is a certain amount of radiation involved. The risks associated with radioactive exposure have been minimised by health professionals in a variety of ways, using the minimum amount of radiation in scanning and adjusting the radiation to body size (for example in children). It is a known fact that high levels of radiation may cause cancer, yet it is highly unlikely that level of radiation used in a CT scan will cause cancer. This risk can be outweighed by the diagnostic benefits from CT imaging in diagnosing other conditions and diseases that are already present. The benefits from CT scans enable detailed images of the internal structure of the body to be viewed and examined for any abnormalities that could be potentially fatal.

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