Wednesday, January 20, 1999

Questions and Answers: Knowing the respiratory system
The questions and answers in this section are designed to help you in protecting your respiratory system and, when necessary, in treating common problems.

Computer doctor
By Luisa Dillner
YOU’VE woken up with a tummy ache that could be due to last night’s kabab, but you feel sure it’s appendicitis. The receptionist at your doctor’s surgery cheerily offers you the next appointment, which is in two weeks’ time. Clutching your side, you sit in front of your computer and find www.gutache.com. You learn that appendicitis causes right-sided pain and that since you’ve not felt sick and are now ready for a fry-up you’re unlikely to need a surgeon’s scalpel.

Travel sickness: some tips
DON’T ever tell the parents with a child who vomits within 10 minutes of the start of a car journey that travel sickness is all in the mind. It can seriously cramp a family’s lifestyle. A colleague of mine sold the car because there was not any point trying to get anywhere with a daughter who threw up with total predictability but no warning on every trip.

Liver transplantation: the current status
By Dr J.D. Wig

Few fields of medicine have generated as much excitement and controversy as the field of transplantation — excitement because transplantation of the heart, the kidney, the lung and the liver can eliminate the morbidity and mortality associated with the chronic failure of these organs; and controversy in large measure to a severe shortage of donor organs.

The spectacular development in liver transplantation has transformed the quality of life for many individuals. Liver transplantation has become standard treatment for end-stage liver disease, acute fulminant liver failure, congenital diseases, tumours, and liver trauma. Each year in Europe alone, more than 3000 patients undergo liver transplantation and expectations for success are high.

Nearly 80% of patients grafted for chronic liver disease are alive and well at one year, and with more than 60% transplanted for fulminant liver failure.

Many centres are reporting 90% one-year survival. European centres have shown a 69% survival rate of five years for chronic liver disease and 55% for acute liver disease; with children fairing better at 85%. About 44% of the patients have been reported to be alive after five years of transplantation.

The enhanced success is multifactoral — greater surgical experience, better graft preservation techniques, and more effective immunosuppression protocol into clinical practice. The result has been a significant reduction in the incidence of acute graft rejection.

Major problems following transplantation are recurrent hepatitis B and C virus infection, drug-related toxicity, and other infections. More effective antiviral and immunosuppressive agents are needed to prevent hepatitis B and C recurrence after liver transplantation.

For patients with end-stage liver and kidney disease, or with enzymatic inherited defects of the liver leading to renal failure, combined liver-kidney transplantation is well tolerated.

Demand for donor livers has been increasing every year. Fundamental issues in organ selection concern organ function and absence of a specific disease. The progressive shortage of organ availability means that we must strive to optimally utilise all liver grafts. Liver failure in childhood continues to present significant dilemmas because of the shortage of paediatric donors.

Ever since the first report of living-related liver transplant (LRLT) in 1989, usually a parent or a relative, over 600 transplants have been performed and good results have been obtained in Japan. In countries where the concept of brain death is not fully accepted as in Japan, transplantation from liver donors is the only treatment of choice for patients with end-stage liver disease.

LRLT has been performed in small children and adults. The advantages include good graft quality, minimum graft injury during preservation and potential immunological benefit. Size mismatching is a major obstacle against its wider application, and requires a complicated and elaborate surgical procedure in comparison with cadaveric whole organ transplantation. About 80% five-year survival has been reported and efforts are continuing to refine operative procedures to pursue even better results. Liver transplantation from living donors is being increasingly accepted usually in coordination with a cadaveric organ programme.

Split liver transplantation (SLT) is a method to increase the number of grafts and is achieving graft and patient survival rates similar to that of whole liver transplantation. SLT is one of the possible approaches to augment the number of livers for transplantation and involves the division of the donor organ into two grafts for two different recipients.

This procedure is more complex than whole liver transplant and is performed sporadically or reserved for emergencies. The recovery of normal hepatic function is slower with SLT. SLT is likely to change the face of cadaveric liver transplantation in the future quite significantly, especially in children. Paediatric liver transplantation has been the driving force behind developing these innovative techniques because in children the shortage of organs has been more critical.

Various other approaches in overcoming the shortage of donor organs for transplantation are: xenotransplantation and hepatocyte transplantation (cell transplantation).

Hepatocyte transplantation is now being increasingly recognised for treatment of terminally ill patients of liver cirrhosis and acute liver failure. However, little is known about the transplantation of liver cells (as compared to pancreas).

For transplantation, the liver cells are harvested from a brain-dead patient human foetuses (post abortion) or from livers of animals like sheep, dogs and pigs. The harvesting procedure requires highly specialised techniques as the hepatocytes have to be separated from the other cells present in the liver. They are then preserved in a special solution which prevents their destruction. They cells should be used for transplantation within hours of the harvesting procedure.

The cells are then injected intraveinously into the abdominal cavity or directly into the vein supplying the liver.

Usually only 50% of the total liver cells in the body need to be provided to produce sufficient liver function. The long-term survival of these cells in the human body has been demonstrated up to 11 months. The procedure of injection may require general anaesthesia initially and to prevent the rejection of these foreign cells, the recipient patient will have to be given drugs which suppress the immune system.

A large number of patients in India are of viral hepatitis - related liver failure. These patients can be salvaged by liver transplantation (still in infancy in India) and hepatocyte transplantation. Acute viral hepatitis-related liver failure is a potentially reversible condition. If some support can be provided to the body during the time the liver cells regenerate, the patient can be fully cured. The transplantation of hepatocytes can be a life-saving procedure for these patients even if hepatocytes survive in the recipient body for a short time.

(Dr Wig, FRCS, is a renowned medical teacher and a famous surgeon.)

Questions and Answers
Knowing the respiratory system

DEEP within the lungs, in hundreds of millions of tiny sacs called alveoli, one of the most crucial of all physiological exchanges takes place: oxygen, which is required by every cell in the body to release energy, is drawn from the air you breathe and enters the red blood cells, while carbon dioxide, a waste product, is given off. The route to this remarkable, life-giving micro-universe is long and tortuous, beginning in the nose and mouth and leading down through the windpipe, or trachea, to the bronchi, the tubes that lead into each lung, and on into even smaller passageways, known as bronchioles. The pathway is reasonably well protected by the nose, which warms and filters the air you breathe, and by the mucous lining that cloaks the system, and is activated by millions of cilia, tiny hair-like projections, that help to move impurities back towards the mouth and nose.

In spite of these safeguards the lungs are directly exposed to the outside world and are bombarded constantly by bacteria and viruses by potentially dangerous pollutants, including those that may be self-administered (such as cigarette smoke), and by airborne irritants (known as allergens) that can cause special problems for those who suffer from hay fever and asthma.

The questions and answers in this section are designed to help you in protecting your respiratory system and, when necessary, in treating common problems. The section also deals with more serious conditions — emphysema, for example, and pneumonia. The best respiratory advice of all, however, is probably the simplest: take care of your lungs and your doctor won’t have to.

What does my doctor actually hear when he puts his stethoscope against my chest?

A stethoscope amplifies the sounds of the air you breathe as it passes in and out of the lungs. By ‘tuning in’ (moving the stethoscope from place to place on your chest and back as he listens), your doctor can get an idea of what’s going on in your bronchi, in your alveoli or air sacs, and in the lower portions of your chest.

Unusual or abnormal sounds may indicate disease. A crackling sound, for instance, may be an indication of pneumonia; high-or low-pitched wheezes an rumbling sounds may signal the presence of an asthmatic condition in the lungs.

Is it better to breathe through the mouth or the nose?

A good question. The nose is better equipped for breathing than the mouth. It has a special filtering system, composed of cilia and mucous membrane, that protects the respiratory tract against impurities (dust, for instance) and invasions of harmful bacteria. The nose also ‘adjusts’ the temperature and humidity of the air before it reaches the lungs. There are times, however, when it is perfectly normal to breathe through the mouth, for example, during heavy exercise.

What is a chronic cough? Is it a symptom that something is wrong?

A chronic cough may indeed be an indication that there is something wrong with your respiratory system. Among the more serious pulmonary conditions that may have a chronic cough as a symptom are bronchitis, lung cancer and tuberculosis.

Suppressing such a cough with over-the-counter medications is not recommended: it may cover up an underlying problem to such an extent that your doctor will have trouble making a correct diagnosis. See your doctor if you have a dry hacking cough, hard coughing spells, chest pains or difficulty in breathing.

Does coughing ever serve any useful purpose?

Yes, it does. When you cough, you are protecting the lower respiratory tract against foreign particles and a build-up of mucus. Coughing helps to bring up unwanted invaders and clear the airways.

A minor cough can be eased by drinking comfortably hot liquids or sucking on lozenges; a humidifier may also help to give relief. Consult your doctor if a cough persists longer than a week or two.

Coughing up rusty-coloured mucus or blood, however, can be a symptom of a serious infection or underlying lungs disease. See your doctor at once.

Is shortness of breath to be expected after a certain age?

Possibly, but not from age alone, pulmonary experts state. Shortness of breath with ordinary activity may increase slowly over the years, depending on how much you cut down on regular exercise. But normally breathlessness shows up only in really strenuous physical activity. Healthy men and women in their fifties or sixties should notice no more difficulty in breathing while walking briskly on level ground than they did in their twenties. When unusual shortness of breath (known as dyspnoea) occurs for no apparent reason, however, it may be the symptom of an underlying disease such as emphysema, asthma or pneumonia, or an early symptom of heart disease. See your doctor if this condition persists.

What can my doctor discover from a chest X-ray?

X-ray are an excellent diagnostic tool which allows a doctor to study the bones and organs inside a patient’s body. These structures show up on X-ray films as varying shades of black and white. Among the diseases that may be diagnosed with the help of chest X-rays are tuberculosis, pneumonia, lung cancer, emphysema, pleurisy and occupational lung diseases.

Are chest X-rays dangerous? Can they increase the risk of cancer?

Generally speaking, chest X-rays do more good than harm. Many lung diseases could not be properly diagnosed without them. But too much of a good thing can turn out to be harmful. X-rays do give off ionising radiation, and this can have a potentially dangerous effect on your cells and genes.

Normally healthy people are no longer required to have yearly chest X-rays but a doctor may suggest this for someone whose work environment is a potentially hazardous one. To guard against excessive exposure to radiation, keep a record of the date, doctor and findings, if any, of any X-ray you have.

I have smoked for years but I feel ok. If I quit now, will my lungs heal and will I reduce the risk of disease?

It is never too late to stop smoking, even after 25 years. Quitting offers both short and long-term benefits. If you feel fine, as you say, you will soon notice some changes once you have given up smoking: you will be able to taste food better and breathe more efficiently; your ‘smoker’s cough’ will clear up. Susceptibility to a wide range of diseases, including various forms of cancer, heart disease, bronchitis, emphysema and ulcers, will be reduced, and chances of enjoying a longer, healthier life will be increased. Research indicates that with each year you stay off cigarettes, the risk of developing such serious illnesses decreases.

Although your lungs will not return to the state they were in before you took up smoking, some of the damage may clear up. The good news, of course, if you do manage to quit smoking, is that your lungs will cease deteriorating further.

How can I stop smoking? I have tried twice before, and both times I went back to smoking.

Although quitting may be difficult, it is not impossible. Thousands of Australians have given up smoking as a result of the Quit. For Life Project, and tobacco consumption in Australia has dropped by 20 per cent in the past ten years. The 1981 census taken in New Zealand revealed that 424000 New Zealanders had recently given up and the Department of Health calculates that a further 44000 had kicked the habit by 1986. Health promotion efforts are now directed mostly at young people to try to persuade them not to start smoking.

Questions your doctor may ask if you have a cough:

• ¨ Has your chronic smoker’s cough recently become more severe?
• ¨ Is your cough accompanied by fever and breathlessness?
• ¨ Is your cough accompanied by chest pain that becomes worse as you inhale?
• ¨ Is your cough brought on by physical exertion, even of the mildest kind?
• ¨ Are you a smoker?
• ¨ Have you ever spat up blood when you cough?
• ¨ Do you have trouble breathing and swallowing when you cough?
• ¨ Do you cough in spasms?
• ¨ Have you recently come in contact with anyone who has a similar cough?
• ¨ What is your occupation?
• ¨ Does a tendency to respiratory problems run in your family?
• ¨ If you aren’t in an upright position when you cough, do you have trouble breathing?
• ¨ What medication are you taking, if any?
• ¨ Do you suffer from any allergies?
• ¨ When did your cough start?
• ¨ If you cough up sputum, how much do you cough up?
• ¨ Are you aware of any special lung problems you might have?
• ¨ Is your only symptom a dry cough?
• ¨ Have you had the same type of chronic cough during previous winter months?

Various organisations and clinics in both countries offer some effective antismoking programmes: check in the Yellow Pages under Smokers Information and Treatment or contact the nearest branch of ASH (Action on Smoking and Health), the National Heart Foundation or the Cancer Society; ask them to send you information or to enrol you in a quit-smoking programme. In addition the Seventh-Day Adventist Church runs group therapy clinics in various centres and issues literature for people unable to attend. All such quit-smoking programmes are usually available at little or no cost. In Australia some employers are offering their employees quit-smoking courses free.

Nicotine is an addictive drug, and some people experience withdrawal symptoms for a limited time (usually about a week or two) but also feel much better immediately. Such temporary discomfort, however, is a small price to pay for ridding yourself of this expensive and dangerous habit. Nor is your past experience unusual — most people have to try several times before they quit for good.

I would like to quit smoking, but I am afraid of putting on a lot of weight.

Does this always happen?

Concern about gaining weight is a problem for most would-be non-smokers. Scientists have found that smoking may affect the amount and types of food smokers eat and how their bodies process the food, causing them to have a lower body weight than non-smokers of the same sex, age and height. Many smokers do gain weight when they quit. But the good news is that these people gain an average of only two to three kilograms. And if you do put on weight. you can probably lose it again after a few months, when you are an established non-smoker and better able to lose weight.

Make quitting smoking your first priority while doing what you can to avoid weight gain. Remember the enormous health benefits of quitting smoking, and don’t allow your worries about gaining weight to get in the way.

Are low-tar, low-nicotine cigarettes safer than others?

There is no such thing as a “safe” cigarette. Low-tar, low-nicotine cigarettes, according to manufacturers’ tests, provide some risk reduction as far as contracting lung cancer and heart disease is concerned. These tests, however, are performed on smoking machines and not on human beings. In addition, switching to a low-nicotine brand is not a reliable alternative to quitting, especially for those who increase the number of cigarettes they smoke to maintain former nicotine levels.

I smoke but I don’t inhale. Am I still injuring my health?

Even though you don’t inhale when smoking, you are holding the smoke in your mouth and thus increasing the risks of developing oral cancer and various other head and neck problems. In addition, you may be inhaling some smoke without being aware of it, and you are breathing in glycoprotein (a tobacco ingredient that may cause some damage to the blood vessels) both during the time you are actually smoking each cigarette and for a while afterwards.

Computer doctor
By Luisa Dillner

YOU’VE woken up with a tummy ache that could be due to last night’s kabab, but you feel sure it’s appendicitis. The receptionist at your doctor’s surgery cheerily offers you the next appointment, which is in two weeks’ time. Clutching your side, you sit in front of your computer and find www.gutache.com. You learn that appendicitis causes right-sided pain and that since you’ve not felt sick and are now ready for a fry-up you’re unlikely to need a surgeon’s scalpel.

With medical information available at the click of a mouse, who, you may ask, needs doctors anyway? How many times have you waited for an hour to see the doctor only to get a six-minute consultation and a diagnosis in Latin? Clutching your list of unanswered questions you marvel at how unassertive you are in a surgery. The Internet, on the other hand, is available 24 hours a day, doesn’t make you feel it’s terribly busy and lets you browse indefinitely.

You can download information for reference and visit more than one site for a second opinion.

In the USA, patients are increasingly being cheated by hospitals run by managed care organisations, which like to save money by limiting costly treatment. So patients use websites to check they’re being given the best and not just the cheapest. Before websites were invented they would have used magazines and encyclopaedias. All are rich sources of health information. My father, for example, diagnosed scoliosis (a curvature of the spine) from reading an article in the New York Times. Much research has been carried out into what patients want from a consultation with their doctors. Generally it’s information. They’d like a cure, but they also want to be listened to and reassured. Some of this they can get from the Internet and even more from e-mail consultations with their doctors. Although these are not in widespread use, they have worked in university health services in the USA, where access to the Internet is high.

A study of over 100 college students using a health promotion computer network found their visits to doctors fell by nearly a quarter. Studies of patients with diabetes who were given dietary education programmes by computer show control of their illness improved dramatically.

The bare bones of a consultation between doctor and patient can certainly be replicated by a computer. Although the consultation is historically seen as detective work in which the doctor works out what’s wrong with you (in at least half of all cases the diagnosis is found by looking to your past health and lifestyle), such history-taking essentially consists of asking a stylised set of questions. Patients can (and in some hospitals already do) easily answer this kind of formulaic list on a computer. In fact, phrasing the questions may be easier than in a human interaction where asking “what seems to be the problem?” can be met with “You’re the doctor.”

Likewise, “What’s brought you to see me today?” can produce “I caught the C12 bus.’’ After the patient has completed the list of questions, the computer or e-mailing doctor may offer some diagnostic suggestions and options for self-treatment. There are obvious limitations to this — resuscitation from a distance doesn’t usually work — but there are also less tangible ones.

Patients may not know whether facts are relevant, and decide to omit them. Patients also tell half-truths and virtual doctors may be more gullible. When asking about alcohol some doctors mentally double what patients have admitted. Or they’ll ask “So how much do you drink a day — a bottle of spirits perhaps?” and see whether the patient looks shocked or is mentally adding up their intake.

And then there’s doctors’ intuition - more reliable with experience.

A computer programme may work rigidly to hospital guidelines, but in a face-to-face interview a doctor may just have a hunch that something’s not right. A doctor I know once insisted a child had a skull X-ray even though her head injury fulfilled none of the hospital criteria for the investigation. The little girl hadn’t been knocked out, sick or amnesiac. The X-ray showed a large fracture.

Telemedicine consultations may allow doctors to diagnose anaemia by seeing patients looking pale, but they won’t be able to feel their sweaty palms and suspect an over-active thyroid. If listening is vital, touching can be even more so. And it’s hard for an e-mail to be effectively sympathetic because it can’t reach for a patient’s hand. A bad prognosis should never be sent by e-mail or read from an impersonal website, which cannot offer hope. Perhaps it’s because doctors are not always effective communicators that the Internet has caught on as a health provider. But the best use of Net information has to be in conjunction with a flesh-and-blood person. Most people will have met a doctor who has magically made them feel better. As Hippocrates said: “Some patients, conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.” It’s unusual for anyone to say that about their computer.
— The Guardian, London.

Travel sickness: some tips

DON’T ever tell the parents with a child who vomits within 10 minutes of the start of a car journey that travel sickness is all in the mind. It can seriously cramp a family’s lifestyle. A colleague of mine sold the car because there was not any point trying to get anywhere with a daughter who threw up with total predictability but no warning on every trip.

Car ferries can be ghastly for motion sufferers. There’s something about the heat and the food smells down in the lounges that used to put me off eating when I was a child, even though I had a cast-iron stomach, while my sister used to have to spend the entire journey on deck.

Strangely, air sickness does not seem to be such a problem these days. Airlines still have the paper bag in the seat pocket in front of you, but how often do you see anybody use it? Perhaps most of us now fly in larger, steadier planes where the motion is not appreciable most of the time.

Travel sickness is explained by the doctors as a mismatch between the message reaching the brain from the eyes and the contradictory information arriving from the ears, which register balance.

The way to deal with it is to reconcile the two messages as far as possible. If in a car or on a boat, you fix your eyes on the horizon and move with the vehicle. You can watch the rolling or swaying motion that the tiny hairs registering balance in your ears are perceiving. Or you can lie down and shut your eyes to block out one set of messages.

The greater the motion, the worse the feeling of nausea, so the best place to sit is the most stable. The back seat of the bus is not a good idea. Sitting between the wings of a plane can help, and the middle of the boat is the best place to be.

Eating heavily is to be avoided as large quantities of food or drink slopping around in the stomach tend to increase the feeling of motion. Dr Jane Wilson-Howarth and Dr Matthew Ellis in their book, “Your Child’s Health Abroad” (produced in the UK by Bradt Publications), recommend light, non-greasy, easily digested food before or during the journey, such as jam sandwiches or small quantities of spaghetti.

“If you travel a lot, make sure your child does not get a mental block about motion sickness; throwing-up is horrible and offering medicines so that children avoid the unpleasantness is kind,’’ they write.

They say the most effective medicine is hyoscine — contained in Kwells and other over-the-counter tablets — although it has the side-effects of drowsiness and a dry mouth. Those who dislike the idea of drugs may want to try elasticated wrist-bands, which are supposed to exert pressure on acupuncture points.

For those who put their faith in herbal cures, the Encyclopaedia of Medicinal Plants (published in the UK by Dorling Kindersley) suggests an infusion of galangal, turmeric or ginger in a flask or chewing crystallised ginger.
(Exclusive to The Tribune from London).