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Jumat, 10 Februari 2017
Tips to have healthy lungs for life
Lung conditions
There are many conditions that can affect your lungs, and the most common are asthma and chronic obstructive pulmonary disease (COPD), chronic lung damage usually (but not always) down to smoking. If you have the inherited condition alph-1 antitrypsin deficiency or bronchiectasis, which cause chronic lung damage even without smoking, you need to pay special attention to any potential outside influences that may cause further problems.
Asthma is closely linked to other allergic conditions like hay fever, and many sufferers find their symptoms are worse in summer, when pollen counts are high. But for the three million COPD sufferers in the UK, it's the advent of winter that brings a special misery. That's largely because many flare-ups of COPD are down to chest infections, which are much more common in the winter months.
In winter it's worth thinking about the steps you can take to protect your lungs. Stopping smoking goes without saying. So does taking any medication (including inhalers) you're prescribed regularly. But many of us underestimate the effect air pollution can have on our health.
If you've ever smoked and suffer from frequent coughs, ask your GP about a breathing test called spirometry to check your lungs. But many of us underestimate the effect air pollution can have on our health.
How does air pollution affect our lungs?
In fact, it's not just people with lung problems who need to take air pollution seriously. Heart conditions, including heart failure, can affect your ability to breathe. So can simply being a little frail. In the long term, it has even been linked to a higher risk of some cancers. So really, air pollution is everyone's problem.
Perhaps the first thing to point out is that pollution isn't an excuse to stay indoors with the windows shut all year. The benefit to your lungs and heart from regular exercise vastly outweighs the harm from pollution. But you do need to take sensible precautions to keep your lungs healthy.
Tips for healthy lungs
Firstly, get into the habit of finding out what pollution levels are on a day-to-day basis. Levels can vary dramatically depending on where you are and what the weather's like. It's time to use your tech savvy to keep up to date. The Met Office has hundreds of weather stations all across the country which put out daily reports not just on the chance of rain but also on air pollution levels. A simple Google search will give you more details. Alternatively, proving that DEFRA isn't just for farmers and vets, you can try their countrywide forecast.
Once you know what pollution levels are on any given day, take them into account. If you have heart or lung problems, consider putting off any strenuous outdoor activity until levels are lower. As soon as you start exercising, you breathe harder and faster, usually through your mouth. This means you take in more air and don't filter pollution out through your nose in the same way.
When you do go out, plan your trip as much as possible to avoid busy roads. Pollution levels drop sharply even a couple of metres away from heavy traffic. Pollution builds up easily in built-up areas full of tall buildings, where air can't circulate.
Where do my medicines come in?
If you take inhalers, make sure you take them really regularly and order your repeat prescription well in advance. If you have COPD, your doctor may give you a 'rescue pack' of medicines to take if you get a cough - don't run out. If you do exercises at home, don't do them too soon after cleaning. Both air fresheners and vacuuming can affect air quality.
What should I look out for?
As for symptoms to look out for, breathlessness or wheezing are the big concerns. But do be aware that irritation in your throat and nose, as well as coughing more, can both be linked to air pollution. Of course, in an ideal world we'd all live in the middle of the countryside, where pollution isn't an issue. But getting your exercise from a regular walk in the park can help your heart, lungs and general fitness without running the risk of undermining your good work.
Jumat, 01 Januari 2016
Hepatitis B Immunisation
Hepatitis B Immunisation
People at increased risk of contracting hepatitis B should be immunised. The hepatitis B vaccine can also be used to prevent infection if, for example, you have had a needlestick injury and you are not immunised. Some people need blood tests to check if they are immune. See your practice nurse if you think you need this vaccine.
What is hepatitis B?
Hepatitis B is an infection caused by the hepatitis B virus. The infection mainly affects the liver. However, if you are infected, the virus is present in body fluids such as blood, saliva, semen and vaginal fluid. In the UK it is estimated that about 1 person in 200 to 1000 is infected with the hepatitis B virus. It varies widely depending on the part of the UK studied. It is much more common in other countries. It is most common in sub-Saharan Africa and East Asia.
If you are infected with the hepatitis B virus, the initial symptoms can range from no symptoms at all to a severe illness. After this initial phase, in a number of cases the virus remains in the body long-term. These people are called carriers. Some carriers do not have any symptoms but can still pass on the virus to other people. About 1 in 4 carriers eventually develop a serious liver disease such as cirrhosis. In some cases liver cancer develops after a number of years. See separate leaflet called Hepatitis B for more details of the disease.
If you are pregnant and are infected with the hepatitis B virus, you can pass it on to your baby as the baby is being born. Vaccinations for the baby can prevent this happening. So all pregnant women in the UK are offered testing for hepatitis B during each pregnancy. If the test is positive, the baby can be protected.
How is hepatitis B passed on?
The hepatitis B virus is passed from person to person in one of these ways:
Hepatitis B is an infection caused by the hepatitis B virus. The infection mainly affects the liver. However, if you are infected, the virus is present in body fluids such as blood, saliva, semen and vaginal fluid. In the UK it is estimated that about 1 person in 200 to 1000 is infected with the hepatitis B virus. It varies widely depending on the part of the UK studied. It is much more common in other countries. It is most common in sub-Saharan Africa and East Asia.
If you are infected with the hepatitis B virus, the initial symptoms can range from no symptoms at all to a severe illness. After this initial phase, in a number of cases the virus remains in the body long-term. These people are called carriers. Some carriers do not have any symptoms but can still pass on the virus to other people. About 1 in 4 carriers eventually develop a serious liver disease such as cirrhosis. In some cases liver cancer develops after a number of years. See separate leaflet called Hepatitis B for more details of the disease.
If you are pregnant and are infected with the hepatitis B virus, you can pass it on to your baby as the baby is being born. Vaccinations for the baby can prevent this happening. So all pregnant women in the UK are offered testing for hepatitis B during each pregnancy. If the test is positive, the baby can be protected.
How is hepatitis B passed on?
The hepatitis B virus is passed from person to person in one of these ways:
- Blood to blood contact. For example, drug users sharing needles or other equipment which may be contaminated with infected blood. (Blood used for transfusion is now screened for hepatitis B virus.) Healthcare workers can be infected through accidental needlestick injuries.
- Having unprotected sex with an infected person.
- An infected mother passing it to her baby.
- A human bite from an infected person. This is very rare.
Who needs hepatitis B immunisation?
Anyone who is at increased risk of being infected with the hepatitis B virus should consider being immunised. This includes:
Workers who are likely to come into contact with blood products, or are at increased risk of needlestick injuries, assault, etc. For example:
Anyone who is at increased risk of being infected with the hepatitis B virus should consider being immunised. This includes:
Workers who are likely to come into contact with blood products, or are at increased risk of needlestick injuries, assault, etc. For example:
- Nurses.
- Doctors.
- Dentists.
- Medical laboratory workers.
- Cleaners in healthcare settings.
- Morticians.
- Prison wardens.
- Police officers and fire and rescue workers.
- Staff at daycare or residential centres for people with learning disabilities where there is a risk of scratching or biting by residents.
- People who inject street drugs. Also:
- Their sexual partners.
- The people they live with.
- Their children.
People who change sexual partners frequently (in particular, sex workers).
People who live in close contact with someone infected with hepatitis B. (You cannot catch hepatitis B from touching people or normal social contact. However, close regular contacts are best immunised.) People who regularly receive blood transfusions (for example, people with haemophilia).
People with certain kidney or liver diseases.
People who live in residential accommodation for those with learning difficulties. People who attend day centres for people with learning difficulties may also be offered immunisation.
Families adopting children from countries with a higher risk of hepatitis B, when the hepatitis B status of the child is unknown. (It is, however, advisable for the child to be tested for hepatitis B.)
Foster carers or if you live with foster children.
Prison inmates. Immunisation against hepatitis B is now recommended for all prisoners in the UK.
Travellers to countries where hepatitis B is common. In particular, those who place themselves at risk when abroad. The risk behaviour includes sexual activity, injecting drug use, undertaking relief work and/or participating in contact sports. Also, if you may need a medical or dental procedure in these countries and the procedure may not be done with sterile equipment.
Babies who are born to infected mothers.
The immunisation schedule
You need three doses of the vaccine for full protection. The second dose is usually given one month after the first dose. The third dose is given five months after the second dose.
One to four months after the third dose you may need to have a blood test. You may need one if you are at risk of infection at work, especially as a healthcare or laboratory worker or if you have certain kidney diseases. Your doctor will be able to advise you if you need a blood test. This checks if your body has made proteins to protect you (antibodies) against the hepatitis B virus. If you have, you will not be able to get it (ie you are immune.)
You may then need a booster dose five years later. There is no need for a blood test before or after this.
The schedule is the same for the combined hepatitis A and B vaccine which is also available.
Rapid immunisation schedule
A schedule of giving three doses more quickly than usual may be used in some situations. That is, three doses with each dose a month apart. An even quicker schedule is also sometimes used. That is, the second dose given seven days after the first and the third dose given 21 days after the first.
These rapid schedules may be used if you are at very high risk of infection and need to be immune as soon as possible. For example, if you are soon to travel abroad, are new to prison or are sharing needles to inject drugs. However, a more rapid schedule may not be as effective for long-term immunity unless a fourth dose is given 12 months after the first dose. Your doctor will advise on the best schedule for your circumstances.
People who live in close contact with someone infected with hepatitis B. (You cannot catch hepatitis B from touching people or normal social contact. However, close regular contacts are best immunised.) People who regularly receive blood transfusions (for example, people with haemophilia).
People with certain kidney or liver diseases.
People who live in residential accommodation for those with learning difficulties. People who attend day centres for people with learning difficulties may also be offered immunisation.
Families adopting children from countries with a higher risk of hepatitis B, when the hepatitis B status of the child is unknown. (It is, however, advisable for the child to be tested for hepatitis B.)
Foster carers or if you live with foster children.
Prison inmates. Immunisation against hepatitis B is now recommended for all prisoners in the UK.
Travellers to countries where hepatitis B is common. In particular, those who place themselves at risk when abroad. The risk behaviour includes sexual activity, injecting drug use, undertaking relief work and/or participating in contact sports. Also, if you may need a medical or dental procedure in these countries and the procedure may not be done with sterile equipment.
Babies who are born to infected mothers.
The immunisation schedule
You need three doses of the vaccine for full protection. The second dose is usually given one month after the first dose. The third dose is given five months after the second dose.
One to four months after the third dose you may need to have a blood test. You may need one if you are at risk of infection at work, especially as a healthcare or laboratory worker or if you have certain kidney diseases. Your doctor will be able to advise you if you need a blood test. This checks if your body has made proteins to protect you (antibodies) against the hepatitis B virus. If you have, you will not be able to get it (ie you are immune.)
You may then need a booster dose five years later. There is no need for a blood test before or after this.
The schedule is the same for the combined hepatitis A and B vaccine which is also available.
Rapid immunisation schedule
A schedule of giving three doses more quickly than usual may be used in some situations. That is, three doses with each dose a month apart. An even quicker schedule is also sometimes used. That is, the second dose given seven days after the first and the third dose given 21 days after the first.
These rapid schedules may be used if you are at very high risk of infection and need to be immune as soon as possible. For example, if you are soon to travel abroad, are new to prison or are sharing needles to inject drugs. However, a more rapid schedule may not be as effective for long-term immunity unless a fourth dose is given 12 months after the first dose. Your doctor will advise on the best schedule for your circumstances.
Are there any side-effects from hepatitis B immunisation?
Side-effects are uncommon. Occasionally, some people develop soreness and redness at the injection site. Rarely, some people develop a mild high temperature (fever) and a flu-like illness for a few days after the injection.
Side-effects are uncommon. Occasionally, some people develop soreness and redness at the injection site. Rarely, some people develop a mild high temperature (fever) and a flu-like illness for a few days after the injection.
What if I come into contact with hepatitis B and am not immunised?
Seek medical attention as soon as possible if you have been at risk from a possible source of infection and you are not immunised. For example, if you have a needlestick injury or have been bitten by someone who may have hepatitis B.
You should have an injection of immunoglobulin as soon as possible. This is an injection which contains antibodies against the virus. It gives short-term protection. You should also start a course of immunisation. The hepatitis B vaccine is very effective at preventing infection if given shortly after contact with hepatitis B. Even if you have had the hepatitis B vaccine and are at risk of infection (for example, by having unprotected sex or sharing contaminated needles), you should ask your doctor for advice. You may be advised to have a booster vaccine or even an injection of immunoglobulin.
Babies who are born to infected mothers should have an injection of immunoglobulin as soon as possible after they are born. They should also be immunised. The first dose of vaccine is given within the first day after birth. This is followed by three further doses at 1 month, 2 months and 12 months of age. At 12 months, immunised babies have a blood test to check that the vaccine has worked.
Seek medical attention as soon as possible if you have been at risk from a possible source of infection and you are not immunised. For example, if you have a needlestick injury or have been bitten by someone who may have hepatitis B.
You should have an injection of immunoglobulin as soon as possible. This is an injection which contains antibodies against the virus. It gives short-term protection. You should also start a course of immunisation. The hepatitis B vaccine is very effective at preventing infection if given shortly after contact with hepatitis B. Even if you have had the hepatitis B vaccine and are at risk of infection (for example, by having unprotected sex or sharing contaminated needles), you should ask your doctor for advice. You may be advised to have a booster vaccine or even an injection of immunoglobulin.
Babies who are born to infected mothers should have an injection of immunoglobulin as soon as possible after they are born. They should also be immunised. The first dose of vaccine is given within the first day after birth. This is followed by three further doses at 1 month, 2 months and 12 months of age. At 12 months, immunised babies have a blood test to check that the vaccine has worked.
Who should not receive the hepatitis B vaccine?
- If you have an illness causing a high temperature, it is best to postpone immunisation until after the illness.
- You should not have a booster if you have had a severe reaction to this vaccine in the past.
The vaccine may be given if you are pregnant or breast-feeding and immunisation against hepatitis B is necessary.
Minggu, 06 Desember 2015
Combined Oral Contraceptive Pill
Combined Oral Contraceptive Pill
The combined oral contraceptive pill (COCP) is often just called "the pill". It contains two hormones - an oestrogen and a progestogen. If taken correctly, it is a very effective form of contraception.
How does the pill work?
It works in three ways:
The pill changes the body's hormone balance so that your ovaries do not produce an egg (ovulate).
It also causes the mucus made by the neck of the womb (cervix) to thicken. This makes it difficult for sperm to get through to the womb (uterus) to fertilise an egg.
The pill also makes the lining of the womb thinner. This makes it less likely that a fertilised egg will be able to attach to the uterus.
There are different types and strengths of oestrogens and progestogens.
How effective is the pill?
About 3 women in 1,000 using the pill correctly will become pregnant each year. Correct use means not missing any pills, re-starting the pill on time after the pill-free week and taking extra contraceptive precautions when necessary - see below. Closer to 90 women per 1,000 will become pregnant with normal (not perfect) usage.
For comparison, when no contraception is used, more than 800 in 1,000 sexually active women become pregnant within one year.
What are the advantages of the pill?
- It is very effective.
- It does not interfere with sex.
- Periods are regular and may be less painful and lighter.
- It relieves premenstrual tension for some women.
- It improves acne in some women.
- It reduces the risk of developing cancers of the ovary, colon and womb (uterus). The protection against cancer of the ovary is quite marked and seems to continue for many years after stopping the pill. It may also reduce the risk of developing certain types of cyst in the ovary.
It may also reduce the risk of pelvic infection (as the thicker mucus prevents germs (bacteria), as well as sperm, from getting into the uterus).
It may help to protect against some non-cancerous (benign) breast disease.
It may help to protect against some non-cancerous (benign) breast disease.
Are there any side-effects when taking the pill?
Most women who take the pill do not develop any side-effects. However, a small number of women feel sick, have headaches or find their breasts are sore when they take the pill. These usually go away within days or weeks of starting the pill. If they continue (persist) there are many different brands of pill you can try, which may suit you better.
Other side-effects are uncommon and include tiredness, change in sex drive, skin changes and mood changes. These are unusual and you should tell your doctor or practice nurse if you have any lasting side-effects. Many people believe that taking the pill makes you put on weight, but this has never been proven in studies.
The pill sometimes causes a rise in blood pressure, so people taking it should have their blood pressure checked every six months. The pill may need to be stopped if your blood pressure becomes too high.
It is common to have some light bleeding between periods when you start the pill. This is nothing to worry about. It usually settles by the end of the third packet. If it does not, you should tell your doctor.
Are there any risks in taking the pill?
The pill can have some serious side-effects, but these are very uncommon. For most women the benefits of the pill outweigh the possible risks. All risks and benefits of you taking the pill should be discussed with your doctor or nurse.
People taking the pill have a small increased risk of getting a blood clot (thrombosis). Blood clots can cause blockages in veins or arteries, and can cause heart attacks or strokes. This is more so in the first year of taking the pill. This is why people with a higher risk of blood clots cannot take the pill. The things that might mean you are at a higher risk are listed in the section "Who cannot take the pill?", below. The risk of a blood clot from taking the pill is considerably smaller than the risk of a blood clot if you were pregnant.
You must see a doctor straightaway if you have any of the following:
- A bad headache, or migraines.
- Painful swelling of your leg.
- Weakness or numbness of an arm or leg.
- Sudden problems with your speech or sight.
- Difficulty breathing.
- Coughing up blood.
- Pains in your chest, especially if it hurts to breathe in.
- A bad pain in your tummy (abdomen).
- A faint or collapse.
These symptoms could be due to a blood clot.
Taking the pill can increase the risk of some types of cancer but also protect against other types. Research into the risk of breast cancer in people taking the pill is complicated and the results are not straightforward. Some studies suggest a possible link between the pill and a slightly increased risk of cancer of the neck of the womb (cervix) if the pill is taken for more than eight years. Some research suggests a link between using the pill and developing a rare liver cancer.
However, there is a reduced risk of developing cancer of the ovary, womb (uterus) and colon in people taking the pill. When all cancers are grouped together, the overall risk of developing a cancer is reduced if you take the pill. Further research is ongoing.
Note: if you need to go into hospital for an operation, or you have an accident which affects the movement of your legs, you should tell the doctor that you are taking the pill. The doctor may decide that you need to stop taking the pill for a period of time to reduce your risk of unwanted blood clots whilst you recover.
Taking the pill can increase the risk of some types of cancer but also protect against other types. Research into the risk of breast cancer in people taking the pill is complicated and the results are not straightforward. Some studies suggest a possible link between the pill and a slightly increased risk of cancer of the neck of the womb (cervix) if the pill is taken for more than eight years. Some research suggests a link between using the pill and developing a rare liver cancer.
However, there is a reduced risk of developing cancer of the ovary, womb (uterus) and colon in people taking the pill. When all cancers are grouped together, the overall risk of developing a cancer is reduced if you take the pill. Further research is ongoing.
Note: if you need to go into hospital for an operation, or you have an accident which affects the movement of your legs, you should tell the doctor that you are taking the pill. The doctor may decide that you need to stop taking the pill for a period of time to reduce your risk of unwanted blood clots whilst you recover.
Who cannot take the pill?
Most women can take the pill. If you are healthy, not overweight, do not smoke and have no medical reasons for you not to take the pill, you can take it until your menopause. Women using the pill will need to change to another method of contraception at the age of 50 years. Your doctor or family planning nurse will discuss any current and past diseases that you have had. Some diseases cause an increased risk or other problems with taking the pill. Therefore, the pill will not be prescribed to some women with certain diseases - for example, hepatitis or breast cancer, or if you are taking certain medicines.
These are some of the conditions which may mean you should not take the pill:
- You are overweight and your body mass index (BMI) is 35 kg/m2 or more. BMI measures how much you weigh related to your height. See our BMI calculator, or your doctor or nurse can work out your BMI.
- You smoke and you are over 35 years of age.
- You are breast-feeding.
- You have high blood pressure (hypertension).
- You have a past history of a blood clot (venous thromboembolism).
- You have a first-degree relative (parent, child, brother or sister) who has had venous thromboembolism under the age of 45.
- You can't walk around or move very well due to major surgery, injury or disability.
- You have had a heart attack or stroke
- You have had angina or circulation problems in your legs (peripheral arterial disease). Note: if you have varicose veins, you CAN take the pill.
- You have several risk factors for heart disease together (such as smoking, being overweight and having diabetes, high blood pressure and a family history).
- You get migraines with an aura. This means before the headache starts your eyesight changes, or you get pins and needles or numbness anywhere before or during the headache. (Headaches other than migraines are not usually a reason not to take the pill.)
- You have or have had breast cancer or liver cancer.
- You have diabetes which has caused problems with your kidneys, eyes or nerves.
- You have certain types of heart problems.
- You have systemic lupus erythematosus (SLE) or Raynaud's syndrome.
- You have a condition which causes your blood to clot differently.
- You are on some types of medication for epilepsy.
Not all these conditions mean you definitely shouldn't have the pill. Your doctor or nurse will be able to work out whether it is safe for you individually. There are very clear guidelines about who should or shouldn't take it, which they can refer to.
How do I take the pill?
There are different brands of pill which contain varying amounts and types of oestrogen and progestogen. There is usually a leaflet inside the packet of pills. Read the leaflet carefully. Make sure you understand how to take the pill and what to do in special situations, such as:
- If you miss a pill.
- If you have been being sick (vomiting).
The following gives a general guide.
Brands with 21-day pills
Most brands of pill come in packs of 21. To start, it is best to take the first pill on the first day of your next period. You will be protected against pregnancy from then on. If you start the pill on any other day, you need an additional contraceptive method (such as condoms) for the first seven days. You should take your pill at about the same time each day for the 21 days.
You then have a break of seven days before starting your next pack. You will usually have some bleeding in the seven-day break, although it may happen later. This is called a withdrawal bleed and is like a period, although strictly speaking it is not a menstrual period. You will be protected from pregnancy during the seven-day break provided you have taken your pills correctly and you start the next pack on time. Start the next pack after the seven-day break whether you are still bleeding or not. If you take the pill correctly, you will start the first pill of each pack on the same day of the week. (It is only when you start the pill for the first time that you take the first pill on the first day of your period. After this, you should ignore your period and start each packet on the same day of the week as the month before. Write down the day of the week you start your first pack, and start all your packets after that on that day.)
Most 21-day pills have the same amount of oestrogen and progestogen in each pill. Some brands, called phasic pills, vary the dose in two or three steps throughout the 21 days. The pills in these packets have to be taken in the correct order as directed on the packet. One type of pill called Qlaira® has a changing dose throughout the cycle, and also needs to be taken in the correct order.
Brands with pills for every day
Most of these contain 21 active and seven dummy pills. There are 28 pills in a packet. Instead of a seven-day break, you carry on taking the dummy pills. As soon as you finish one packet, you go on to the next. The idea is that you don't have to remember to restart the pill after a seven-day break and you develop a routine of taking a pill every day. The pills have to be taken in the correct order. Read the instructions carefully, particularly on when to start, which pill to start with, and how long it takes for the contraceptive effect to begin. The newer pills Qlaira® and Zoely® are slightly different. In these pills there are 28 pills in the packet. Qlaira® has two dummy pills, as well as changing doses throughout the cycle. Zoely® has four dummy pills, and all the other pills in the packet are the same dose. These pills are also taken without a seven-day break.
Brands with 21-day pills
Most brands of pill come in packs of 21. To start, it is best to take the first pill on the first day of your next period. You will be protected against pregnancy from then on. If you start the pill on any other day, you need an additional contraceptive method (such as condoms) for the first seven days. You should take your pill at about the same time each day for the 21 days.
You then have a break of seven days before starting your next pack. You will usually have some bleeding in the seven-day break, although it may happen later. This is called a withdrawal bleed and is like a period, although strictly speaking it is not a menstrual period. You will be protected from pregnancy during the seven-day break provided you have taken your pills correctly and you start the next pack on time. Start the next pack after the seven-day break whether you are still bleeding or not. If you take the pill correctly, you will start the first pill of each pack on the same day of the week. (It is only when you start the pill for the first time that you take the first pill on the first day of your period. After this, you should ignore your period and start each packet on the same day of the week as the month before. Write down the day of the week you start your first pack, and start all your packets after that on that day.)
Most 21-day pills have the same amount of oestrogen and progestogen in each pill. Some brands, called phasic pills, vary the dose in two or three steps throughout the 21 days. The pills in these packets have to be taken in the correct order as directed on the packet. One type of pill called Qlaira® has a changing dose throughout the cycle, and also needs to be taken in the correct order.
Brands with pills for every day
Most of these contain 21 active and seven dummy pills. There are 28 pills in a packet. Instead of a seven-day break, you carry on taking the dummy pills. As soon as you finish one packet, you go on to the next. The idea is that you don't have to remember to restart the pill after a seven-day break and you develop a routine of taking a pill every day. The pills have to be taken in the correct order. Read the instructions carefully, particularly on when to start, which pill to start with, and how long it takes for the contraceptive effect to begin. The newer pills Qlaira® and Zoely® are slightly different. In these pills there are 28 pills in the packet. Qlaira® has two dummy pills, as well as changing doses throughout the cycle. Zoely® has four dummy pills, and all the other pills in the packet are the same dose. These pills are also taken without a seven-day break.
What if I miss or forget to take one or more pills?
Read the leaflet that comes with your brand of pill for advice on what to do. Your ovaries could produce an egg (ovulate), and therefore you could become pregnant, if you miss pills. This is particularly a risk if the missed pills are at the end or beginning of the packet. The advice depends on how many pills you have missed, and when they were missed in the cycle. If you are 24 hours late, or more, taking your pill, it counts as a missed pill.
If one pill is missed, anywhere in the pack, take the missed pill now. This may mean taking two pills in one day. You should take the rest of the pack as usual. No extra contraception is needed. You should have the seven-day break as normal.
If two or more pills are missed anywhere in the pack, take the last missed pill now. This may mean taking two pills in one day. Any earlier missed pills should not be taken. You should take the rest of the pack as usual. You should also use extra precautions (ie use a condom or don't have sex) for the next seven days.
You may need emergency contraception (the morning after pill or similar) if you have had unprotected sex in the previous seven days and have missed two or more pills in the first week of a pack. This also applies if you start your pack two or more days late.
You should start the next pack of pills without a break, if there are fewer than seven pills left in the pack (after the missed pill).
If you are unsure what to do, or are unsure that you have taken the pill correctly, use other forms of contraception (such as condoms) and seek advice from a doctor or nurse.
Note: if you are on the pills called Qlaira® or Zoely® this advice may not apply. The information that comes with the packet should tell you what to do if you miss pills. If you are still not sure, ask your doctor or nurse.
Do other medicines interfere with the pill?
Yes, some do but most do not. Therefore, before you take any other medicines, including those available to buy without a prescription, herbal and complementary medicines, ask your doctor or pharmacist if they stop the pill from working properly. He or she will advise you on what to do.
For example, some medicines that are used to treat epilepsy and tuberculosis (TB) can stop the pill from working properly. St John's wort is an example of a commonly used herbal remedy that can affect the pill.
Antibiotic medicines
Antibiotics (other than one called rifampicin) do not interfere with the effectiveness of the pill. In the past it was recommended that, if you were taking antibiotics and were also taking the pill, you should use additional contraception. This is no longer the current recommendation after more recent evidence has been reviewed. You should continue taking your pill as normal if you also need to take any antibiotics.
What if I am sick (vomit) or have diarrhoea?
If you vomit within 2-3 hours of taking a pill, the pill will not have been absorbed. If you are well enough, take another pill as soon as possible. Provided that you do not vomit this second pill and it is taken on the same day, you will remain protected from pregnancy. If you continue to vomit, the advice is the same as missing pills (see above). Mild diarrhoea does not affect the absorption of the pill. Severe diarrhoea may affect it and if you have severe diarrhoea, consider this as the same as missing pills (see above).
What happens if I don't have a withdrawal bleed (period) between packs?
It is normal to have bleeding during the seven-day break between pill packs (or when taking the dummy pills in pills taken every day). However, it is quite common for there to be no bleeding between pill packs. You are not likely to be pregnant if you have taken the pill correctly and have not been sick (vomited) or taken any medicines that can interfere with the pill. Start the next pack after the usual seven-day break and continue to take your pill as usual. Do a pregnancy test or see your doctor or nurse if:
- You don't have any bleeding after the next pack (two packs in total); or
- You have not taken the pill correctly; or
- You have any reason to think that you may be pregnant.
A pregnancy test may be advised.
Bleeding whilst on the pill (breakthrough bleeding)
During the first few months, while your body is adjusting to the pill, you may have some vaginal bleeding in addition to the usual bleeding between packs. This is not serious but more of a nuisance. It may vary from spotting to a heavier loss like a light period. Do not stop taking your pill. This usually settles after the first 2-3 months. If it continues (persists), see your doctor or nurse. Another brand of pill may be more suitable for you.
Bleeding whilst on the pill (breakthrough bleeding)
During the first few months, while your body is adjusting to the pill, you may have some vaginal bleeding in addition to the usual bleeding between packs. This is not serious but more of a nuisance. It may vary from spotting to a heavier loss like a light period. Do not stop taking your pill. This usually settles after the first 2-3 months. If it continues (persists), see your doctor or nurse. Another brand of pill may be more suitable for you.
Can I delay or skip a withdrawal bleed (period)?
There are times when it is useful not to have a period - for example, during exams or holidays. Check with your doctor or nurse about the best way to do this with your particular brand of pill. For the commonly used pill types (that is, not bi-phasic or tri-phasic or the pills that are taken every day with 28 pills in the packet) you can go straight into your next pack without a break. Have the usual seven-day break at the end of the second packet.
Kamis, 01 Oktober 2015
Infant colic - a knife to the heart
Infant colic - a knife to the heart
A baby's cry is designed to cut straight to your heart. It's a primeval urge, to want to protect your young. Without it, mankind would probably never have survived - after all, if a baby didn't cry when they were in trouble, their parents wouldn't know when they needed protecting. But that's exactly why a baby's constant crying for hours at a time, for days or weeks on end, can drive parents to despair.
And that's exactly what colic is. Technically, infant colic is inconsolable crying in a baby with no evidence of anything physically wrong with them. It starts in the first few weeks of life, and almost always disappears as mysteriously as it started, by the age of about three or four months. That means it only last a few weeks - but they can seem to last a lifetime. Crying is often worse in the late afternoon and evening, and babies will often arch their back and/or bend up their knees.
Developing coping strategies that work for you is key - that may include sleeping when your baby is sleeping, calling on family and friends to allow you to take some time out (any one of them who's been a parent will know how you feel!) and speaking to your health visitor or doctor. It can be easy to lose sight of the fact that this isn't your fault - which it categorically isn't. I often find mothers feel terribly guilty about leaving their baby for even a minute - yet by getting a break, they'll be in a much better position to cope with those tough few weeks.
One of my jobs as a GP is to check to see if there's anything seriously wrong. This is much less likely if your baby is feeding, pooing, weeing and growing normally. Likewise, if they're entirely well between bouts of crying, and the crying tends to happen at the same time of day, colic is high on the list of likely diagnosis. However, I only diagnose colic when I've asked about other conditions.
A baby who suddenly starts crying inconsolably could, occasionally, have conditions like torsion of the testis, a strangulated hernia or intussusception, where one part of the bowel slides forward into another part and gets trapped. If crying keeps happening, we'll be thinking about the possibility of:
- Reflux (especially where babies are refusing feeds, refluxing a lot of milk after every feed or having problems gaining weight)
- Cow's milk protein allergy
- Constipation.
If colic is at the root of your baby's crying, it can be reassuring to know that it will settle on its own. In the meantime, gentle movement (rocking the cradle is the obvious one, but lots of babies seem to fall asleep when they're being driven); 'white noise' (from a running tap, hairdryer or vacuum cleaner) or a warm bath may help. Holding your baby may help, but if you need time out, don't feel bad about putting them in their cot for a bit.
Your health visitor can offer advice and reassurance, and may be able to put you in touch with other mums in a similar situation - it makes it so much better to know it's not just you. If all else fails, a one-week trial of simeticone drops (such as Infacol®) or lactase drops (such as Colief®) may help. If it helps, keep going until your baby is about four months old, then wean off over the course of a week or so. If one doesn't help after a week, try the other.
But most important of all, try not to take it personally. Colic is miserable for you and your baby but it's definitely not your fault. Once they've grown out of it, they'll forget all about it. As for you? With a bit of luck it'll soon seem like a very bad dream - and you can get on with enjoying your bundle of joy.
Selasa, 25 Agustus 2015
Frozen shoulder
Frozen shoulder: key facts to know
It may be the season for ice creams, but one thing you don't want frozen in summer - or any time of year - is your shoulder. Otherwise known as 'adhesive capsulitis of the shoulder', a frozen shoulder can be very painful, as well as limiting your ability to function normally. Most common in your 40s to 60s, frozen shoulder affects about one in 30 people at some point. Oddly, it most commonly affects the arm you don't write with.
Frozen shoulder symptoms can last for two to three years. They tend to start with a 'freezing up' phase, when your shoulder becomes painful and gradually more and more stiff. In phase two, the 'frozen' phase, the pain often gets better but stiffness can get worse, until you can hardly move your shoulder. Twisting your shoulders outwards (eg to put your hands behind your head) can be especially difficult. Finally comes the 'thawing' phase as the pain eases and movement gradually gets back to normal. Each phase can last several months.
On the plus side, there are several treatments to ease symptoms and lightning - or at least freezing - rarely strikes the same shoulder twice.
What causes a frozen shoulder?
Your shoulder joint is lined with a thin protective capsule. Doctors aren't sure exactly why scar tissue can build up in the capsule, causing it to thicken, stiffen and shrink.
How can I help myself?
Shoulder pain and strains are very common - partly because the shoulder is such a complicated joint, with a 'cuff' of strong connective tissue and lots of muscles which allow it to move in every direction. There's a lot to go wrong! Not all shoulder pains end up with a frozen shoulder. If you get shoulder pain, it's important to move your shoulder in all directions several times a day to cut the risk of it stiffening up. Your doctor can advise on exercises
What are the treatments?
Painkillers like paracetamol (with codeine if necessary) can help relieve pain. So can anti-inflammatory tablets or gels containing ibuprofen or naproxen, which will cut inflammation as well. Warm or cold compresses (never apply ice directly on to your skin) may also ease symptoms. If your symptoms don't settle quickly or seem to be getting worse, your doctor may refer you to a physiotherapist. They can give you regular exercises and may offer a TENS machine, which provides tiny electrical currents that can help with pain. A steroid injection into the joint, while not a permanent cure, can cut pain and inflammation for several weeks.
Surgery for frozen shoulder
If your shoulder is still causing problems despite proper courses of other treatment, you may be offered one of two kinds of surgery, both under general anaesthetic. The first involves moving your shoulder in all directions, to break down the scar tissue. The second is keyhole surgery using an 'arthroscope' - your surgeon will stretch the shoulder capsule and remove scar tissue. In both cases you'll be offered follow-up physiotherapy to keep it mobile.
Doing the dislocation
Your shoulder is a 'ball and socket' joint and the socket (at the top outer corner of your shoulder blade) is very shallow. That means it's relatively easy to push the ball out of the socket in a heavy fall. About 95% of shoulder dislocations are anterior - the ball at the top of the humerus (upper arm bone) is pushed forwards. Sporting injuries are the most common cause in younger people, while in older people it's mostly a fall on to an outstretched arm. You can't fail to notice it - your shoulder will be very painful, you won't be able to move it and you may see a lump. Take yourself straight to A&E for an X-ray to check no bones are broken, and the doctor will manipulate it back into place under sedation. You'll need to wear a sling for a few weeks and see a physiotherapist regularly. You'll feel better within a couple of weeks but complete recovery can take up to four months.
Frozen shoulder symptoms can last for two to three years. They tend to start with a 'freezing up' phase, when your shoulder becomes painful and gradually more and more stiff. In phase two, the 'frozen' phase, the pain often gets better but stiffness can get worse, until you can hardly move your shoulder. Twisting your shoulders outwards (eg to put your hands behind your head) can be especially difficult. Finally comes the 'thawing' phase as the pain eases and movement gradually gets back to normal. Each phase can last several months.
On the plus side, there are several treatments to ease symptoms and lightning - or at least freezing - rarely strikes the same shoulder twice.
What causes a frozen shoulder?
Your shoulder joint is lined with a thin protective capsule. Doctors aren't sure exactly why scar tissue can build up in the capsule, causing it to thicken, stiffen and shrink.
How can I help myself?
Shoulder pain and strains are very common - partly because the shoulder is such a complicated joint, with a 'cuff' of strong connective tissue and lots of muscles which allow it to move in every direction. There's a lot to go wrong! Not all shoulder pains end up with a frozen shoulder. If you get shoulder pain, it's important to move your shoulder in all directions several times a day to cut the risk of it stiffening up. Your doctor can advise on exercises
What are the treatments?
Painkillers like paracetamol (with codeine if necessary) can help relieve pain. So can anti-inflammatory tablets or gels containing ibuprofen or naproxen, which will cut inflammation as well. Warm or cold compresses (never apply ice directly on to your skin) may also ease symptoms. If your symptoms don't settle quickly or seem to be getting worse, your doctor may refer you to a physiotherapist. They can give you regular exercises and may offer a TENS machine, which provides tiny electrical currents that can help with pain. A steroid injection into the joint, while not a permanent cure, can cut pain and inflammation for several weeks.
Surgery for frozen shoulder
If your shoulder is still causing problems despite proper courses of other treatment, you may be offered one of two kinds of surgery, both under general anaesthetic. The first involves moving your shoulder in all directions, to break down the scar tissue. The second is keyhole surgery using an 'arthroscope' - your surgeon will stretch the shoulder capsule and remove scar tissue. In both cases you'll be offered follow-up physiotherapy to keep it mobile.
Doing the dislocation
Your shoulder is a 'ball and socket' joint and the socket (at the top outer corner of your shoulder blade) is very shallow. That means it's relatively easy to push the ball out of the socket in a heavy fall. About 95% of shoulder dislocations are anterior - the ball at the top of the humerus (upper arm bone) is pushed forwards. Sporting injuries are the most common cause in younger people, while in older people it's mostly a fall on to an outstretched arm. You can't fail to notice it - your shoulder will be very painful, you won't be able to move it and you may see a lump. Take yourself straight to A&E for an X-ray to check no bones are broken, and the doctor will manipulate it back into place under sedation. You'll need to wear a sling for a few weeks and see a physiotherapist regularly. You'll feel better within a couple of weeks but complete recovery can take up to four months.
Minggu, 23 Agustus 2015
Appendicitis - what's the point?
Appendicitis - what's the point?
The appendix used to be useful - now it's just a trouble maker. Tucked away at the very start of your large intestine, where it joins the small intestine just behind your right pelvic bone, it's not thought to do anything useful in modern man. It probably helped digest food when we lived on a tough fibrous plant diet. It may play a small part in fighting off disease through our immune system, acting as a reserve of 'good' bacteria which can emerge after a bout of gastroenteritis and help get the gut into shape again. But removing it does no long-term harm at all - which is fortunate, because the only time most of us give it any thought is when it gets inflamed and needs to be removed.
Up to one in 10 people get appendicitis. While it's most common between the ages of 10 and 20, much older people can be affected - as Elton John discovered in August 2013, when he was well past the first flush of youth.
Everyone knows that appendicitis causes tummy pain - more specifically, pain in the bottom right- hand side of the abdomen. But in fact, occasionally appendicitis can happen without pain in this part of the abdomen at all - particularly in pregnant women, where the appendix is pushed up by the growing womb. What's more, in early appendicitis pain is more commonly situated round the tummy button, moving down and right over the next few hours or sometimes days. It's usually made worse by coughing, moving or even deep breathing, and feeling or being sick, along with fever, become more marked as time progresses.
Because the appendix sits very close to the right ureter - the tube your urine passes down between your kidney and your bladder - inflammation of the appendix can irritate the ureter, causing a need to pass water often. In fact, a urine infection can sometimes be mistaken for appendicitis, as can kidney stones, ovarian cysts, ectopic pregnancy (a pregnancy outside the womb), or pelvic infection caused by sexually transmitted infection.
In children, it's not uncommon for inflamed lymph nodes in the tummy to cause symptoms that can be mistaken for appendicitis. Inflammation of the bowel from other causes, such as Crohn's disease or colitis can also mimic appendicitis.
Any pain in the right lower tummy which is bad enough to stop you sleeping or wakes you from sleep should be checked out, especially if you have any of the symptoms above. While I hasten to add that I don't recommend a 'diagnose-it-yourself' approach, hints that you shouldn't just hope for the best include pain accompanied by:
- Feeling or being sick
- Being off your food
- Constipation (or diarrhoea)
- Fever
- Pain that starts around the belly button and moves south-east
- Marked tenderness when you press just above the right hip bone
- Pain in the lower right stomach when you press the lower left side.
You may be surprised to discover that even if you're admitted to hospital and your doctor thinks you might have appendicitis, you won't necessarily be rushed straight to surgery. There's no foolproof way of diagnosing appendicitis, and up to one in five people who have their appendix removed don't have appendicitis at all. So your doctor will do blood tests and urine tests to see how much inflammation is going on in your body and whether urine infection, kidney stone or pregnancy could be to blame. The may also recommend:
- An ultrasound or CT scan
- A urine test or a protein called LRG (not widely available on the NHS, and still going through trials, but LRG is often very raised in appendicitis and the test may be done routinely in the future)
- Antibiotics, either to delay the need for surgery (which might make it safer) or to see if surgery can be avoided.
If you have all the classic symptoms of appendicitis, your doctor will probably want to operate sooner rather than later to avoid your appendix perforating. This lets the gut contents out into the abdominal cavity and can cause serious infection called peritonitis. At worst peritonitis can be life-threatening; at best it means you'll take longer to recover. But if your symptoms are less obvious, your doctor may recommend a 'wait and see' policy to avoid unnecessary surgery.
On the plus side, most people can have their appendix taken out using keyhole surgery, and are out of hospital in as little as 24 hours. Your appendix will always be examined under a microscope after it's removed to exclude the tiny chance that you have a tumour called carcinoid. You'll take a week or two to get back to normal, and you should avoid heavy lifting in the short term. As for the longer term? Doctors aren't going to remove your appendix for no reason, but you and your appendix can part company without you ever having to worry for your future health.
On the plus side, most people can have their appendix taken out using keyhole surgery, and are out of hospital in as little as 24 hours. Your appendix will always be examined under a microscope after it's removed to exclude the tiny chance that you have a tumour called carcinoid. You'll take a week or two to get back to normal, and you should avoid heavy lifting in the short term. As for the longer term? Doctors aren't going to remove your appendix for no reason, but you and your appendix can part company without you ever having to worry for your future health.
Kamis, 09 Juli 2015
Multiple sclerosis: key facts to know
Multiple sclerosis: key facts to know
In my experience, people dread the thought of getting multiple sclerosis (MS) every bit as much as cancer. It's much less common - about one in 1,000 people in the UK get it, compared to one in 10 women diagnosed with breast cancer alone. Perhaps it's because people know there's a hope that cancer can be cured, while MS can't. Perhaps it's because it tends to strike so young - the average age of diagnosis is just 32.
MS causes a wide variety of symptoms affecting the nervous system, which can strike at any time. They include dizziness, numbness and tingling over parts of the skin, balance problems, blurred or double vision, muscle weakness and waterworks problems. Eighty per cent of people get the 'relapsing remitting' type of MS - between attacks of symptoms, usually lasting two to six weeks, they feel completely well. Over time, remissions between attacks may get fewer and shorter. In time, up to two thirds of sufferers will develop memory problems of some sort.
The state of MS
A recent survey of MS patients and their doctors reveals the full extent of the impact of MS. It also shows that we need to keep working to improve communications between doctors and patients.
One in five hospital specialists say they limit the discussions they have with MS patients to 'need to know' information, to protect them. Yet 90 per cent of people with MS want to know everything about their condition, whether good or bad.
Eighty per cent of sufferers said that MS affected hobbies and social activities. Almost half said it had an impact on their everyday activities, and three quarters said it made it harder (or impossible) to work.
But the survey has good news too. In the UK, nearly half of people with MS have access to a specialist MS nurse, who may have more time to discuss everyday concerns and how to cope with them. In the rest of the world, this figure is just nine per cent.
What causes MS?
MS is an 'autoimmune' disease - your body's immune system, which normally helps you fight off infection, turns on you and attacks the insulating sheaths around the nerves that carry messages inside, to and from your brain. The whole cause still isn't completely clear. We know genetics plays a part - one in five people with MS have a relative with the condition. But it's not the whole story - 99% of people with a parent or sibling with MS don't get it. We know viral infections may trigger the start of symptoms, and can often bring on relapses - but everyone gets viral infections and only one in 1,000 people in the UK have MS. It seems to be a complicated combination of 'nature and nurture'.
Vitamin D - is there a link?
The 'sunshine vitamin' may protect against MS - chillier parts of Scotland have up to twice the rate of MS found in England. Consider a daily supplement of 20 micrograms of vitamin D if you don't get much sun.
MS - what help is out there?
The NHS has made remarkable progress in providing help for all the physical, practical and psychological problems that MS sufferers face. Most hospitals have specialist clinics, with a team of healthcare professionals. Physiotherapists can help with strength and balance problems; occupational therapists with adaptations needed for the home; speech and language therapists with speech or swallowing issues; specialist nurses offer advice on medication and side effects; and counsellors can offer talking therapy.
MS treatments - what's new?
We have seen a lot of progress in recent years in 'disease-modifying' treatments, which cut relapse rates and can slow progression of the disability caused by MS. Beta-interferon and Copaxone® have been shown to reduce relapse rates by 30 to 40 per cent. Tysabri® and Gilenya® may cut them by 50-70 per cent. Now a new tablet, Tecfidera®, has also been approved by NICE, the medicines regulator. It has been shown to cut relapse rates and the chance of having symptoms in relapsing-remitting MS by almost half. Because not all medicines work for or suit all patients, the more medication options we have, the more hope.
Selasa, 07 Juli 2015
When diabetes blinds
When diabetes blinds
One of my patients was diagnosed with diabetic macular oedema this week - and she's terrified. She said she had no idea that complications of type 2 diabetes could be so serious. I've been on a crusade for decades to help spread the word that type 2 diabetes is NOT a 'mild' kind of diabetes - without good control, it can blind and, make no mistake, kill.
In many respects type 1 and type 2 diabetes are very different conditions. Type 1 diabetes is an autoimmune disease not linked to lifestyle or weight, while type 2 diabetes is (almost) all about weight and lifestyle. But in terms of long-term complications there are many similarities. They're both diagnosed on the basis of raised blood glucose, and that raised glucose can cause similar complications in both - kidney problems; eye disease; and nerve damage which can lead to ulcers or even amputation of the foot. People with type 1 and type 2 diabetes are also at increased risk of heart attack.
High blood sugars over several years can weaken and damage the blood vessels at the back of the eye, which supply blood to the retina (the layer of cells that send messages about what you're seeing to your brain). This is known as diabetic retinopathy. It can result in leakage of fluid from the blood vessels, tiny bleeds, little bubbles of weakened vessel walls (called microaneurysms) and problems with the blood supply to the retina. New blood vessels grow to try to improve the blood supply, but these blood vessels are easily damaged and can harm your eyesight.
The macula is a small part near the middle of your eyesight that is tightly packed with light-sensitive cells. It allows you to see in fine detail. In severe diabetic retinopathy, fluid and scar tissue can build up on the macula, causing a condition called macular oedema. Diabetic macular oedema affects about 50,000 people in the UK - it's the commonest preventable cause of blindness in adults of working age.
In the past, there was little or no treatment for diabetic retinopathy or macular oedema, other than using tight glucose control to try to stop it worsening. That's still important today, but now we have two main options for treatment, depending on how bad your symptoms are. The first is laser surgery to seal off the abnormal new blood vessels growing on the back of the eye .
The second is the injection of vascular endothelial growth factor (VEGF) inhibitor medicines - Lucentis® is licensed for treatment of diabetic macular oedema, and now the National Institute for Health and Care Excellence (NICE) has approved a new drug for some people. Eylea® has already been approved by NICE for another condition affecting the macula, called age-related macular degeneration but this new approval increases the options available for people whose eyesight is threatened by diabetic macular oedema.
But these treatments are only needed if the condition develops in the first place, and prevention is always better than cure. In both type 1 and type 2 diabetes, a healthy diet, regular exercise and tight control of your blood pressure, cholesterol and blood sugar can all help cut your risk of complications. But regular eye checks are also essential.
We're incredibly lucky in this country - the NHS Diabetic Eye Screening Programme is the envy of the world. Virtually no other country has a system for annual eye screening for everyone with diabetes over 12 years old - once a year, you'll be offered a 30-minute appointment which involves dilating your pupils with drops and taking photographs of the retina at the back of your eye. This checks for diabetic retinopathy and if early signs and symptoms are found, you'll either be called back for follow-up sooner or referred on to a specialist with a view to assessing you for treatment.
Both problems get more likely with increasing length of diabetes - few people have any diabetic retinopathy if they've had diabetes for under five years, but up to one in person in three who has had diabetes for 25 to 30 years will have some degree of macular oedema. That doesn't mean you can ignore it until then - by taking preventive steps and getting regular eye checks from an early stage, you could just avoid becoming a statistic.
Minggu, 05 Juli 2015
Frozen shoulder: key facts to know
Frozen shoulder: key facts to know
It may be the season for ice creams, but one thing you don't want frozen in summer - or any time of year - is your shoulder. Otherwise known as 'adhesive capsulitis of the shoulder', a frozen shoulder can be very painful, as well as limiting your ability to function normally. Most common in your 40s to 60s, frozen shoulder affects about one in 30 people at some point. Oddly, it most commonly affects the arm you don't write with.
Frozen shoulder symptoms can last for two to three years. They tend to start with a 'freezing up' phase, when your shoulder becomes painful and gradually more and more stiff. In phase two, the 'frozen' phase, the pain often gets better but stiffness can get worse, until you can hardly move your shoulder. Twisting your shoulders outwards (eg to put your hands behind your head) can be especially difficult. Finally comes the 'thawing' phase as the pain eases and movement gradually gets back to normal. Each phase can last several months.
On the plus side, there are several treatments to ease symptoms and lightning - or at least freezing - rarely strikes the same shoulder twice.
What causes a frozen shoulder?
Your shoulder joint is lined with a thin protective capsule. Doctors aren't sure exactly why scar tissue can build up in the capsule, causing it to thicken, stiffen and shrink.
How can I help myself?
Shoulder pain and strains are very common - partly because the shoulder is such a complicated joint, with a 'cuff' of strong connective tissue and lots of muscles which allow it to move in every direction. There's a lot to go wrong! Not all shoulder pains end up with a frozen shoulder. If you get shoulder pain, it's important to move your shoulder in all directions several times a day to cut the risk of it stiffening up. Your doctor can advise on exercises
What are the treatments?
Painkillers like paracetamol (with codeine if necessary) can help relieve pain. So can anti-inflammatory tablets or gels containing ibuprofen or naproxen, which will cut inflammation as well. Warm or cold compresses (never apply ice directly on to your skin) may also ease symptoms. If your symptoms don't settle quickly or seem to be getting worse, your doctor may refer you to a physiotherapist. They can give you regular exercises and may offer a TENS machine, which provides tiny electrical currents that can help with pain. A steroid injection into the joint, while not a permanent cure, can cut pain and inflammation for several weeks.
Surgery for frozen shoulder
If your shoulder is still causing problems despite proper courses of other treatment, you may be offered one of two kinds of surgery, both under general anaesthetic. The first involves moving your shoulder in all directions, to break down the scar tissue. The second is keyhole surgery using an 'arthroscope' - your surgeon will stretch the shoulder capsule and remove scar tissue. In both cases you'll be offered follow-up physiotherapy to keep it mobile.
Doing the dislocation
Your shoulder is a 'ball and socket' joint and the socket (at the top outer corner of your shoulder blade) is very shallow. That means it's relatively easy to push the ball out of the socket in a heavy fall. About 95% of shoulder dislocations are anterior - the ball at the top of the humerus (upper arm bone) is pushed forwards. Sporting injuries are the most common cause in younger people, while in older people it's mostly a fall on to an outstretched arm. You can't fail to notice it - your shoulder will be very painful, you won't be able to move it and you may see a lump. Take yourself straight to A&E for an X-ray to check no bones are broken, and the doctor will manipulate it back into place under sedation. You'll need to wear a sling for a few weeks and see a physiotherapist regularly. You'll feel better within a couple of weeks but complete recovery can take up to four months.
Kamis, 02 Juli 2015
Ovarian cancer screening - light at the end of the tunnel?
Ovarian cancer screening - light at the end of the tunnel?
A diagnosis of cancer is scary enough, but women have good reason to fear a diagnosis of ovarian cancer almost above all others. While ovarian cancer is the fifth most common cancer among women in the UK, it's one of the most deadly.
Breast cancer rates are much higher - over 48,000 women are diagnosed with this most common cancer every year in the UK, and rates have increased by more than 50% in the last 25 years. But survival rates for breast cancer have improved dramatically in recent years, with more than 80% of women surviving for at least 5 years from diagnosis (compared to 50% in the 1970s) and twice as many women as in the 1970s surviving for 10 years.
Sadly, the same improvements have not been seen with ovarian cancer. While about 7,100 women are diagnosed with ovarian cancer a year in the UK, 4,200 die from it each year. One of the reasons for this is that many women have advanced cancer by the time they are diagnosed. There are early warning signs, but some women don't seek help early because they put their symptoms down to other conditions like irritable bowel syndrome, or IBS. But IBS rarely develops for the first time in anyone over 50, and it usually starts before you're 40.
The 'red flag' symptoms include:
- Persistent bloating
- Feeling full quickly or loss of appetite
- Persistent stomach or pelvic pain
- Needing to pass water more often.
These symptoms need checking out if they're persistent (they don't come and go) or if you get them frequently over any length of time, especially on more than 12 days a month.
There are also screening tests - one is an ultrasound scan of the pelvis, which can pick up growths on the ovary. The other is a blood test called Ca125.
It's crucial to be certain that screening tests save lives before jumping in with whole population screening. The UK breast screening programme is estimated to save 1,300 lives a year, but at a cost of 4,000 women having unnecessary surgery. That's because screening can throw up 'false positive' results, where initial screening suggests cancer might be present but none is found on further testing. Screening can also miss cancers (so-called false negative results), which might mean people being lulled into a false sense of security and ignoring symptoms.
Just four years ago, a 10-year American study of almost 40,000 women, given a Ca125 blood test annually for the first six years and a yearly ultrasound for the remaining four, failed to show any improvements in survival from ovarian cancer in the screened group. Worse still, there were over 3,000 'false positive' results among the screened women. More than 1,000 women underwent unnecessary surgery and 222 had 'major complications' from treatment for a condition that wasn't there.
The difference between this trial and previous ones is that it tracked trends in Ca125 for each woman. This allowed the researchers to personalise the results, deciding on what constituted a raised level based on the woman's previous results rather than using a single cut-off point. As a result, about a quarter of women found to have cancer were diagnosed in the earliest stages - currently, three quarters of women first present with symptoms when their cancer has reached an advanced stage.
But there is still no guarantee that getting a diagnosis and treatment earlier using this approach translates into lives saved - final figures on survival rates of the trial are expected at the end of this year. Doctors would also need to weigh up how much over-treatment from false positives will result - and there's no doubt that there will be false positives. Then there would be the question of whom to screen. While ovarian cancer can occur at any age, the highest number of cases is seen in women in their 60s and the risk increases with age. Start too young and complications of the resultant unnecessary treatment could cost more lives than it saves.
This means that even if screening is introduced, it will almost certainly start too old to benefit women like Angelina Jolie, who carry the faulty BRCA gene. So there's a very long way to go before we conquer this deadly disease, or even see the sort of revolutions in treatment we've achieved for breast cancer. But every little helps, and this might just help more than a little.
Sabtu, 27 Juni 2015
Beating bowel cancer
Beating bowel cancer
A recent publicity campaign by the charity Bowel Cancer UK urged us 'Don't die of embarrassment' - and they meant it literally. Never a day goes by in my surgery when I don't get at least one patient mumbling in a sheepish way about blood from their bottom. Sometimes they've waited days before they pluck up courage to make an appointment. Often they seem terrified that I'm going to look disgusted - but nothing could be further from the truth. Not only is your GP completely used to people telling them about problems with their bowels, they're positively pleased they have. And that's because the more people who come forward, the better our chances of beating bowel cancer.
The earlier you're diagnosed with bowel cancer, the sooner you get treatment. And the sooner you get treatment, the greater the chance that your cancer will be at an early stage, where it hasn't spread. To put this into perspective, people diagnosed at the earliest stage (stage A) have a greater than 90% chance of beating the disease. What price a little embarrassment when the stakes are so high?
Who's at risk?
Anyone can get bowel cancer, although it does get more common as you get older. But if bowel cancer runs in your family, you could be at higher risk so speak to your GP - they may recommend regular screening.
The symptoms you need to know
- Symptoms you need to get checked out include:
- Bleeding from your back passage, especially if it's dark (rather than bright red) blood, and the blood is mixed in with your stool (rather than on the paper or the toilet pan)
- A change in your usual bowel habit, especially if you're passing more frequent or looser motions
- A feeling of not emptying your bowel completely when you go to the toilet
- Persistent tummy pain, being off your food or losing weight for no reason.
- Your GP can usually reassure you there's nothing to worry about, but it's MUCH better to be safe than sorry!
How can I reduce my risk?
Eating plenty of fruit and vegetables can cut your risk of colon cancer, as well as protecting you from heart attack and stroke. Fruit and veg are high in fibre, which protects against colon cancer, constipation, piles and diverticular disease. It may even cut your risk of type 2 diabetes. Other sources of fibre in your diet include wholemeal/wholegrain foods and oats. Taking regular exercise lowers your risk - it's estimated that one in 20 bowel cancers in the UK are linked to people doing less than 30 minutes of exercise, five times a week. Limiting your intake of alcohol, processed and red meat and keeping your weight down will also protect you.
Aspirin - should I or shouldn't I?
Taking a regular 'baby aspirin' (75 mg) tablet a day may cut your risk of colon cancer. Recent studies suggest that taking this dose daily for 10 years between the age of 50 and 65 could reduce your risk by a third. If you've had a heart attack or stroke, you should definitely be taking this anyway unless there's a medical reason you shouldn't. However, aspirin does carry a risk of bleeding from the stomach, so for some people the risks might outweigh the benefits. Speak to your doctor before you start on a regular dose.
The envelope through your door you should never ignore
A simple test could save your life - all you need to do is put it in the postbox. Every two years from the age of 60-74 (in England and Wales), 60-71 (in Northern Ireland) or 50-74 (in Scotland) you'll receive a letter with a 'faecal occult blood' (FOB) test kit. This checks for invisible traces of blood in your faeces. You just use the scraper in the kit to take a tiny sample of three different bowel motions from your toilet paper. You wipe it gently on to the card provided, seal it in the prepaid envelope and return it. Most people have a normal result - people with a positive test are called back for further tests, but most of these are later given the all clear. Even if it's positive, getting early treatment improves your chance of cure greatly - it's estimated that 2,500 people a year could be saved with this test.
Rabu, 24 Juni 2015
Have a heart for your health
Have a heart for your health
Have a heart for your health
Less than six inches long, your he
We're learning more every year about what keeps your heart ticking, and these days your GP will be keeping a careful eye on your risk of heart attack and cholesterol levels if you're over 40. Raised blood pressure and cholesterol don't cause any symptoms in the short term, but they're major risk factors for all the heart problems we're talking about today. So it's essential to get your blood pressure and cholesterol checked at least once when you reach 40, then as often as your GP advises. If you're on blood pressure or cholesterol-lowering medication, do try to take it regularly - ask your pharmacist for a 'dosset box' if it makes it easier to remember to take your medication - and go back for regular checks. Your heart deserves it!
art works tirelessly day and night, pumping blood round your body to keep your organs supplied with vital oxygen. It contracts about 100,000 times every day - so it's not surprising that just sometimes, it runs out of juice.We're learning more every year about what keeps your heart ticking, and these days your GP will be keeping a careful eye on your risk of heart attack and cholesterol levels if you're over 40. Raised blood pressure and cholesterol don't cause any symptoms in the short term, but they're major risk factors for all the heart problems we're talking about today. So it's essential to get your blood pressure and cholesterol checked at least once when you reach 40, then as often as your GP advises. If you're on blood pressure or cholesterol-lowering medication, do try to take it regularly - ask your pharmacist for a 'dosset box' if it makes it easier to remember to take your medication - and go back for regular checks. Your heart deserves it!
A. Angina
Angina causes similar, but usually less severe, symptoms to those of a heart attack, and means you're at higher risk of a heart attack in future. Treatment is less urgent but broadly similar.
Heart failure
The term sounds terrifying, but 'heart failure' just means that your heart isn't pumping blood round your body effectively enough to stop fluid building up. It gets much more common with age - about one in 15 of those aged 75-85 and one in seven of those aged over 85 are affected - but the symptoms can usually be effectively treated with tablets. There are several underlying causes, including heart attack, high blood pressure or atrial fibrillation.
The excess fluid can build up in your legs, causing swollen ankles, or in your lungs, with shortness of breath, which may be worse if you try to lie flat and sometimes a cough. You can also get tiredness, dizziness and loss of appetite.
If your doctor suspects heart failure they'll refer you to a hospital heart specialist. The mainstay of treatment is water tablets (diuretics) to remove the excess fluid and treat the symptoms, but you'll also be given other tablets to cut the chance of symptoms returning.
B. Atrial fibrillation
The most common abnormal heart rhythm in the UK, atrial fibrillation, or AF affects about 1.2 million people in the UK and rising. Like heart failure, it gets more common with age. It can cause palpitations (your heart rate becoming very fast and irregular), and sometimes shortness of breath, dizziness or chest pains. But some people don't know they have it until they have their pulse checked.
Perhaps the most important complication of AF is stroke - fortunately, regular treatment with blood-thinning agents like warfarin (aspirin is no longer recommended) cut this risk dramatically.
Heart attack
We all know the 'classic' signs of a heart attack - central crushing chest pain, shortness of breath, dizziness. But women are less likely than men to feel severe chest pain, and more likely to have back pain, feeling sick and/or severe tiredness. It's crucial to dial 999 if you think you're having a heart attack - new treatments have dramatically improved survival rates for heart attack, but they need to be given fast. Depending on the kind of heart attack you've had and how quickly you arrive, you may be offered emergency surgery or 'clot-busting' drugs to reopen the artery that has become blocked.
C. How can I help myself?
Whether it's angina, heart attack, heart failure or AF, the risk factors - and the advice - are largely the same.
Discover a diet that's heart-healthy: the Mediterranean diet - rich in a rainbow of fruit and veg, low in refined carbohydrates (including sugary and processed foods) and red meat, high in wholegrain or wholemeal foods, nuts and fish - has consistently been proved to protect your heart.
Best foot forward: regular 'aerobic' exercise (the kind that makes you mildly out of puff) works wonders for your heart health. If you've had a heart attack, you should be offered 'cardiac rehabilitation' to help you.
Stub it out for good: you know what I'm talking about! Stopping smoking is the single best thing you can do for your heart - speak to your doctor about getting support.
Whether it's angina, heart attack, heart failure or AF, the risk factors - and the advice - are largely the same.
Discover a diet that's heart-healthy: the Mediterranean diet - rich in a rainbow of fruit and veg, low in refined carbohydrates (including sugary and processed foods) and red meat, high in wholegrain or wholemeal foods, nuts and fish - has consistently been proved to protect your heart.
Best foot forward: regular 'aerobic' exercise (the kind that makes you mildly out of puff) works wonders for your heart health. If you've had a heart attack, you should be offered 'cardiac rehabilitation' to help you.
Stub it out for good: you know what I'm talking about! Stopping smoking is the single best thing you can do for your heart - speak to your doctor about getting support.
Sabtu, 20 Juni 2015
Stroke in the headlines
Stroke in the headlines
Forget 'Love is All Around Us' - judging by this month's headlines, it's more a case of 'Stroke is All Around Us.'
On 2 May we heard that Ruth Rendell, the famous crime writer, had died as a result of a stroke she suffered earlier this year at the age of 85. Then yesterday came the news that Jimmy Greaves had also had a stroke. This footballing legend - 4th on the list of England's top all-time list of scorers in international matches - suffered a severe stroke on 10 May, but he had previously had a less serious stroke in 2012, at the age of 72. If a patient of mine dies from a stroke at the age of 85, I often hear their families murmur about them having had 'a good innings'. With the average age of stroke being 75, Jimmy Greaves' case is sad but perhaps not shocking.
Personal stories of stroke are always tragic, but perhaps even more worrying for the population as a whole is today's news. We tend to think of stroke as an old person's condition - I've been taught that the risk of stroke doubles every decade from the age of 55, and one in five women and one in six men will have a stroke by the age of 75 (1).
But new statistics from the Stroke Association shows a rise of over 45% in stroke admissions in England over the last 14 years for men aged 40-54 - up from 4,260 in 2000 to 6,221 in 2014. Figures for women of the same age were slightly less horrendous, but still increased by almost a third from 3,529 to 4,604. They concede that improved treatments for stroke in recent years may have meant patients being more likely to be admitted to hospital for treatment with minor strokes which would have been treated at home in the past - due to the Department of Health's 'Act FAST' campaign, but they warn that this is not enough to account for the whole rise. They also warn that if we keep going the way we are, we could wipe out the advances in stroke rates achieved by cutting smoking rates across the UK from 45% in 1974 to under 20% today.
The Stroke Association describe the increase as a 'sad indictment' of the nation's health, and place the blame squarely at the door of our lifestyle habits. Although high blood pressure is the single biggest risk factor for stroke, obesity is the risk factor which has been changing most rapidly in the UK - and not for the better. More than one in four UK adults are now obese, and excess weight is a common link for many of the stroke risk factors - high blood pressure, raised cholesterol, type 2 diabetes.
About one in six strokes in the UK is due to atrial fibrillation, or AF, the commonest abnormal heart rhythm in the UK, which affects over a million people. AF also gets more common with age, but can affect younger people, and it's largely related to the same risk factors as other forms of stroke.
Of course there are lies, damned lies and statistics, and this dramatic 50% increase only translates to an extra 2,000 men a year. But imagine being cut off in your prime, reduced overnight from a worker and family breadwinner to being completely dependent on others for the simplest acts of daily life. Do I get bored with endlessly reminding my patients - and my readers - of the importance of healthy lifestyle changes? Not when the stakes are this high
About one in six strokes in the UK is due to atrial fibrillation, or AF, the commonest abnormal heart rhythm in the UK, which affects over a million people. AF also gets more common with age, but can affect younger people, and it's largely related to the same risk factors as other forms of stroke.
Of course there are lies, damned lies and statistics, and this dramatic 50% increase only translates to an extra 2,000 men a year. But imagine being cut off in your prime, reduced overnight from a worker and family breadwinner to being completely dependent on others for the simplest acts of daily life. Do I get bored with endlessly reminding my patients - and my readers - of the importance of healthy lifestyle changes? Not when the stakes are this high
Jumat, 19 Juni 2015
Take care of your kidneys
About seven years ago, hospital laboratories routinely introduced a new blood test for kidney function. Called the eGFR, it measured how efficiently your body's filter, the kidneys, were doing their job. Overnight, great swathes of my practice population were labelled as having 'chronic kidney disease', or CKD and many of them panicked. As we've learned since then, many needed nothing more than a yearly blood and blood pressure test and they could stop worrying.
CKD is defined on the basis of your eGFR reading and whether there's protein in your urine which has leaked out through your kidneys. An eGFR reading of over 60 is normal; 30-59 is stage 3 CKD; 15-29 is stage 4; and under 15 is stage 5.
If your eGFR drops too low (under 15), you need dialysis or a kidney transplant. But this is the exception. Everyone's eGFR drops with age. But a gradual drop is usually fine and even normal, depending on your age - it's a rapid fall-off that doctors worry about. If your blood pressure is well controlled, an eGFR level of 50 or 55 when you're 70 is fine if it stays pretty stable year on year. In fact, your kidneys will probably outlast you!
A. Kidney disease - who's at risk?
The risk factors for chronic kidney disease are, on the whole, the same as for heart attack and stroke. Diabetes and high blood pressure are the most common culprits. However, other conditions affect either just the kidneys - among them glomerulonephritis and adult polycystic kidney disease - and conditions such as lupus and Henoch-Schönlein purpura can also damage the kidneys.
B. Kidney disease - what can I do about it?
If you have CKD, your kidneys are more at risk if you get dehydrated. Do keep up your fluid intake in the summer (unless you've been advised not to). And do speak to your doctor if you get a tummy bug, which increases your risk of dehydration.
If you don't have diabetes, (type 1 or type 2) the key to protecting your kidneys is to keep your blood pressure controlled. If you're under 75 or so, your doctor may want to get your blood pressure down below 140/90 or even 130/80. Blood pressure control is also paramount for people with diabetes, but tight blood sugar control also plays a major part in protecting your kidneys.
Two groups of blood pressure-lowering medicines called the ACE inhibitors (they all have names ending in '-pril' and the ARBs (all with names ending in '-sartan') offer extra protection to your kidneys.
C. Drug alert!
Some medicines can damage your kidneys. Others are filtered out of the body by your kidneys. This means if you have CKD, the levels might build up to dangerous levels. Your doctor will keep an eye on your tablets and may drop the dose or change some tablets if your kidney function drops.
Most people don't come to harm with anti-inflammatory drugs like naproxen and ibuprofen, but in some people they're toxic to the kidneys. If you've been taking anti-inflammatory drugs for some time and your doctor suggests you should stop them, this may be why.
D. Diabetes and your kidneys
If you have type 1 or type 2 diabetes your medical team should check your urine for glucose and a blood test for your kidney function at least once a year. That's because high blood sugar can damage your kidneys. And that's one reason it's important to take your medication and get regular diabetes check-ups. Other complications of diabetes related to high blood sugar include eyesight problems and nerve damage, which can cause pain in the legs or foot ulcers. Paying attention to your diet and taking your blood sugar-lowering medication will protect against these, too.
E. What happens if my kidneys fail?
Without treatment, you couldn't live if your kidneys weren't filtering harmful waste and excess water from your body. So thank goodness for treatment! More than 40,000 people in the UK live with kidney failure. Some have had a kidney transplant, but more than half have regular dialysis. There are two main kinds of dialysis - in the most common kind, haemodialysis, you spend about three four-hour sessions a week 'hooked up' to a machine that filters all the toxins from your body. Many people live for years on this regular treatment. Having a kidney replacement removes the need for dialysis but involves taking regular medicines to stop your body rejecting your kidney.
Rabu, 17 Juni 2015
Easing wheezing
When I was a girl, we used to call a really nasty cold a 'sneezy-wheezy-can't-breathe-easy'. Actually, most people who get a cold don't get wheezy. But people who have other lung conditions like asthma or chronic obstructive pulmonary disease (COPD) often find that a cold makes them wheezy, and wheezing can definitely make breathing harder.
Wheezing is a sort of whistling sound as air passes through a narrowed airway. This partial blockage, which stops oxygen getting into the bloodstream effectively, also causes shortness of breath and sometimes chest 'tightness'. In conditions like asthma and COPD, wheezing tends to come from the very small airways deep in the lungs. Sometimes, inflammation in the larger airways, the bronchi, can also make it hard for air to get through, causing wheezing. The medical term '-itis' means inflammation, and inflammation of the bronchi is called 'bronchitis'.
A. What causes wheezing?
Any inflammation of the airways, causing them to constrict, can cause wheezing. Often this is triggered by infection or irritation (allergy, smoke, chemicals etc). The most common causes of wheezing are asthma and COPD. In asthma, it's caused by narrowing of the small airways (bronchioles) of the lungs - but this narrowing is temporary. In someone with well-controlled asthma, the lungs work normally. In COPD, there's often a mixture of narrowed airways (usually caused by lung damage to the 'spokes' in the small airways that keep them open), thickening of the walls of the small airways (making it harder for oxygen from the lungs to reach the bloodstream) and sticky mucus deep in the lungs.
B. Preventers and relievers
For both asthma and COPD, inhalers can be divided into 'relievers' (give rapid relief but usually work for a few hours only) and 'preventers' (that need to be taken regularly to reduce inflammation and cut flare-ups). 'LABAs', or long acting beta agonist inhalers do a bit of both.
If your symptoms aren't controlled with inhalers, your doctor may recommend regular tablets which also act long-term to cut inflammation or wheeze. In very severe COPD, you may need an oxygen supply.
C. Asthma
Asthma most commonly starts in childhood and often runs in families. The main symptoms are wheezing, shortness of breath, cough and chest tightness. The constriction of the airways that causes wheezing can be brought on by infections, allergy (to pollen or animals etc), dust, cigarette smoke, exercise or temperature change.
Treatment for asthma starts with a 'reliever' inhaled medicine that opens up the small airways, allowing air to pass easily. If this isn't enough, regular inhaled steroids, then a longer lasting airways-opener, will be added.
With well-controlled asthma you shouldn't be waking at night due to symptoms; shouldn't be needing to use your 'reliever' more than a few times a week and should be able to live, work and exercise normally. Signs of a severe asthma attack include severe wheezing and breathlessness not relieved by your 'reliever' inhaler and especially being too breathless to speak - see a doctor urgently.
D. COPD
This used to be called 'emphysema' or 'chronic bronchitis' - usually caused by smoking, it causes wheeze, shortness of breath and chest tightness. Unlike asthma, you're also more prone to infections settling on your chest and the obstruction to your airways isn't reversible, so your lungs will never be as good as new. Along with 'reliever' and 'preventer' medications, key tips include:
a. Stopping smoking to prevent further damage
b. Having a regular flu vaccine and a vaccine against pneumonia
c. Keep active (your doctor can advise about 'pulmonary rehabilitation' classes to get you started)
d. Keeping a 'rescue' supply of antibiotics to start as soon as your sputum becomes more cloudy or you start coughing more, and a course of steroid tablets if your breathing and wheezing get worse
e. Seeing a doctor if your 'rescue' supply isn't helping.
E. Wheezy bronchitis
In children especially, viral (or bacterial) infections can cause inflammation of the bronchi and wheezing. This doesn't necessarily mean they have, or will get, asthma and often settles as their airways get bigger with age.
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