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Obstructive Sleep Apnoea and Snoring….by Eghosa Imasuen

We all know the relative or roommate or spouse who snores, who keeps us awake at night with generator and construction-worksite-like noises. And a few of us suspect that those who snore are blissfully unaware that they disturb us, that they might be affecting our health. But we do not suspect the health implications associated with snoring.

One of my anaesthesiology professors once asked me, during an operation he was covering, what the major sign of respiratory obstruction was. I racked my brain, reeling off highfalutin answers to this seven-worded query. Big answers to a little question. The real answer was little too. He told me: noisy breathing. One of the obvious signs that someone is having trouble breathing is noisy breathing. We already know this from the asthmatic wheeze, from the stridor of infantile epiglottitis and crackles of pneumonia. This is also true with snoring.

With snoring, the person suffers from a structural predisposition to obstruction. Whether from overweight, or from faulty anatomy, the person’s upper airways—i.e., the part of the breathing apparatus above the lungs, the throat, pharynx, and mouth—are prone to collapse during the deep sleep. This person normally doesn’t have any problems when awake as the muscles that keep the airways patent are working. But when they fall asleep, that is when the problems arise.

There are several stages of sleep. The initial phases in which there are varying levels of arousability—here the muscles are still under conscious control, even if they are unaware of this—and REM (Rapid Eye Movement or Dream) sleep. When we fall into REM sleep, our muscles are at their most relaxed state. The throat collapses, and if there was a pre-existing tendency to obstruction, the person snores. Now, as in all things in life, there is a spectrum of severity ranging from the small cute whistling snore, to the bring-down-the-house generator-noise type.

This brings us to the most common form of Obstructive Sleep Apnoea, OSA, and its consequences. In some cases of snoring, the obstruction becomes complete, the airways fully blocked off, and the patient stops breathing. We have observed this in relatives and friends. Some mischievous ones call this “changing gear.” When this happens, carbon dioxide levels in the blood rise and “awaken” the person. Conscious control of the airways is achieved and for a short while the snoring stops, and starts again. This cycle is repeated throughout the night. The end effect of this is that the patient does not sleep well. For years, the person’s brain has not been reaching its full resting state. There is associated morbidity with this: from increased somnolence (i.e., the tendency to drop off into sleep during the waking hours); to tiredness and irritability; structural defects in the brain’s blood circulatory architecture, we call this Cerebro-vascular Disease (CVD); increased predisposition to strokes, to the small-small strokes that doctors call lacuna infarcts that can lead to multi-infarct dementia; to a type of heart failure called cor pulmonale.

During the investigations in hospital of a patient with OSA, a sleep study is carried out by the ENT (ear, nose, and throat) surgical department. A multidisciplinary approach is advocated for OSA management. There are treatments. There is first the advice that the person loses weight. There is advice on sleeping positions; lie prone or on your side, the back sleeping position worsens snoring, and OSA. There is a machine called the continuous positive airway pressure (C-PAP) machine. This comes with a mask, or nasal canellas that are worn during sleep. Its name is self-explanatory. Models designed for the peculiarities of our environment come with rechargeable batteries. There are also surgical options for therapy. The option chosen by your doctor will depend on the results of your consultation and the subsequent investigations.

So, if you know a relative who snores, who seems to stop breathing during the night, whom you have to nudge repeatedly to stop the snoring; or you have been told by friends and relatives that you snore really badly and you find yourself increasingly tired during the day? Then go and see your doctor. It might be a sign of impending morbidity. There is no better evidence of the truth in the statement that a stitch in time saves nine.

I Feel Pain When I Laugh….by Peju Adeniran

When Sylvia* came to the hospital for the first time, it was on Sunday morning, when most people were in church. Infact, she came in straight from church, dressed in her Sunday best, bent over in pain and holding a note from her pastor.

The note read: “Please doctors, attend to Miss Sylvia* X, she is a worker who had to be excused from the church service because of ill-health.”

Well, she didn’t need a note to see a doctor in a public hospital, Anyway, alone with the female doctors, Sylvia undressed shyly, and proceeded to show us one of the most painful-looking inflamed hemorrhoids I had ever seen.

I wondered to myself how she had managed to walk, sit and stand properly, with that kind of swelling coming from her intestines.

While on her side and undressed, Sylvia told me that the pain from the piles was so bad especially when she was making a bowel movement, that she had trained her body to stop using the toilet all together.
“I got tired of seeing blood whenever I went in there, and sometimes I avoid going to where people crack jokes, because my bum bum pains me when I laugh hard.”

A hemorrhoid or “pile” occurs when a vein in the anus becomes swollen with blood, which has become trapped in it. Blood normally passes unhindered through the veins in the anus, back into the body and then returns back unhindered. But some conditions occur, when this blood flow is obstructed because of unusual pressure on them.

When the veins are blocked, it can also cause some degree of irritation to the skin above the veins, thereby causing the pain the people who suffer from hemorrhoids experience.

Hemorrhoids are one of the most popular illnesses in our society today. Not because they are most common in incidence, but because amongst those that practice and advertise “traditional medicine cures” they are frequently advertised as one of the conditions that people should come to them for.
 Sylvia had been consulting at a “traditional medicine” place for about two years with no relief before she eventually sought treatment from the hospital that Sunday morning.

She had been asked to drink various herbs; some of which were even inserted up into her, where the piles were, all to no relief.

As she wept on the table that day, I thought of how much easier her life could have been if only she knew a few things.

One, there are many possible treatments for piles, but by far the best, would be to not have gotten the piles in the first place. It is definitely a case of prevention being the best medicine.

How is this possible, you ask? By taking better care of our insides and intestines we can prevent this condition.

Sylvia, like most people who suffer from this condition, consumes a lot of processed carbohydrate foods, without including fiber; which she could have gotten from raw fruits and vegetables

She also confessed to me that since she went to a boarding school she had trained herself to not use the toilet regularly, which means she was often constipated.

Her daily water intake, from the consumption chart we drew up was also not impressive, meaning she didn’t also hydrate her intestines properly.

Eventually these bad habits caught up with Sylvia, and she ended up in pain, on the Doctor’s examination bed and being prescribed corrective surgery.

So, to prevent the condition above, it is wise to take care of your intestines by avoiding Sylvia’s unhealthy habits. It is also important to exercise often; weight gain, especially in the abdomen has been known to contribute to piles.

Pregnant women, because of their growing abdomen are, unfortunately, susceptible to piles, but thankfully, it is only temporary.

Here’s a fun fact to consider: people who sit for long on the toilet bowl, because of the pressure on the anal veins, with no support from under, could be increasing their risk for piles as well.

So, if you think that the toilet is the best place to read that newspaper or your new novel, you could be inviting PILES.

*she is well now, and allowed me share this story with you all.

The Curious Case Of The Everlasting Cough (2)….by Peju Adeniran.

Whenever I think of drug addiction in the young, Bariga comes to mind.

And even though I had lived in Lagos all my life, I did not think much of Bariga as a place, until one day, during a psychiatry rotation in school, a patient who was fighting drug addiction revealed that he was hooked on crack cocaine, a commodity that he easily bought off his friends who lived on the streets in Bariga. He said, he regularly bought wraps, for a mere 50 naira a hit.

The cheap price was going to be the first of my many surprises with drug addiction, as, for instance, I would later learn that in Northern Nigeria for example, a popular narcotic concoction of choice was made by boiling laundry blue, herbs and lizard droppings. (http://news.bbc.co.uk/2/hi/africa/2131440.stm ).

Another lesson, was realizing that many drug addicts did not necessarily use the narcotics or hard drugs that we have come to know and expect. In spite of available street drugs, most young addicts, (young in age and young in addiction) prefer to lean towards “softer” drugs at first, than to start at the top.

They like to use drugs, which they believe are cleaner, drugs they can “pull back from” believing that those ones are less addictive, and that they can stop them anytime they want.

That’s where Codeine falls into. If you recall, Codeine which has now become a ‘popular,’ ‘clean,’ and ‘soft’ drug came to my attention when a patient mentioned that her son had been on cough syrup for a very long time with no apparent relief from his symptoms, and also from the case of a woman who had seen children buy this cough syrup from a pharmacy with the help of an adult.

Weeks later, another case came up where a male senior secondary school student in a prestigious Nigerian school was found not only to have been abusing Codeine but had set up a lucrative business buying the bottles of cough syrup in bulk and selling in school to his classmates.

Matters came to a head when he was reported to the school by the parents of one of his customers who had had confessed his source. A search was carried out and hundreds of empty bottles of cough syrup were found under his bed.

His business had been going on for a long time, and everyone was amazed by how much money he had amassed by the time his business went bust. (The money was enough to amaze even his rich parents).

A codeine-high in a young person looks like this; a blunt, happy or dreamy expression all the time, with a reluctance to have an emotional response to anything; it is hard for people like this to get angry or anxious, some are immune to most physical pain.

It’s the classic prescription-drug addiction effect that has been described in movie and music stars; Michael Jackson being a famous example.

Now you can ask me; how could the parents have missed it in their children? Quite easy; they must have thought they had happy, easy going children.

Unfortunately, I was not privy to how the story ended. In spite of my efforts to follow up on how treatment for the addicted patient was sought and effected, not much was heard of how the case ended.

I still think of that case from time to time, and I am now deeply suspicious of people who come to me for cough medication especially those that recommend what medication I should prescribe for them especially when it involves codeine. In my head, I wonder if they planned on having an “everlasting cough” so I usually write a prescription for: “lots of rest, multivitamins and honey, then get back to me.”

We need to fight this everlasting cough epidemic!

Ice Cream Is Good And Bad For You….Eghosa Imasuen

I remember the anecdotes associated with these words of wisdom, after a period of enjoyment comes a bout of payback. Valentine’s Day was just some weeks ago and I know that some of my readers had ice cream, or at least bought ice cream. How many of those who swallowed the creamy stuff, luxuriating in the coolness, the ease with which it went down the throat, the taste of cow’s milk percolated into fatty cream, and then frozen, ended up in the toilet within hours? If you were one of them, you have Lactose Intolerance.

Lactose intolerance is a condition—completely misnamed, since contrary to what the title suggests, it is actually the normal state for adult mammals—in which the ability to digest the sugar, lactose, is impaired because of a lack of the enzyme lactase. The etymology of the words lactose and lactase are self-explanatory. Lactose is the predominant sugar found in milk. And in adults, the frequency of absence of the enzyme lactase in populations ranges from 5% in Northern Europe, and some pastoral communities in Africa, to 71% in Sicily and up to 90% in Africa and Asia.

What happens is this: lactose is a disaccharide, a sugar made of two smaller units. Disaccharides cannot be absorbed directly through the intestine’s walls. So when a lactase-deficient individual ingests milk, the sugar remains in the lumen of the gut where it is immediately acted upon by bacteria. This fermentation produces by-products, gas: hydrogen, carbon dioxide and methane. These in turn produce the intestinal symptoms some of you remember from the 15th of February: cramps, bloating, heartburn, and flatulence, and of course, diarrhoea. Although to be pedantic, the way Lactose Intolerance produces diarrhoea is through the direct action of the undigested sugar itself, not through the action of bacteria. The sugar draws water into the lumen of the gut leading to the watery stools.

But what is the real-world relevance of Lactose Intolerance, you ask. You see, in the northern-hemisphere-dominated world we live in, assumptions can lead to, and have led to, death. During the Nigerian Civil War, Caritas, the Catholic aid agency, and others pushed large shipments of aid to help the protein-energy-malnourished children in the Biafran enclave. They came with egg yolk, with dried fish, with milk. And doctors, including the pair who would go on to found Médecins san Frontières, noticed that older children were dying from consuming milk. From consuming milk? Yes. The Red Cross initially ascribed these deaths to spoilage, to contamination, to even outright poisoning by the opposing forces. They said Biafrans were preparing the milk wrongly. But it was Lactose Intolerance. Even the brilliant can be slow to latch onto the obvious.

Lactase is an enzyme that every child is born with, an important trait because the infant’s entire diet consists of mother’s milk. The mammalian production of lactase drops off as infants approach the weaning period but some populations—because of a mutation in the genes that code for this trait—have retained the ability to process lactose into adulthood. Unsurprisingly this recent agriculturally associated trait confers an advantage in pastoral communities, so lactose intolerance is rare in societies where dairy products have a long, almost prehistoric, history of being consumed, i.e., the Fulani, the Tutsis, and Northern Europeans. However, most other humans lose this ability. And it is not modifiable, although new research seems to suggest that retaining Lactase activity into adulthood is on the rise worldwide, a sign, some say, of evolution in action.

So those who stole to mommy’s kitchen cupboard to binge on powered milk; those who add coffee to their milk instead of vice versa; those who quaffed Valentine’s Day ice cream as if there was no tomorrow, now you know why you ended up in the loo hours later.