Dr. Piyush Gupta Articles

Dr. Gupts's
Health & Well-being Page

November 6, 2008

Hare Krishna

Please accept my humble obesainces, all glories to Srila Prabhupada

This month I thought about writing few things on insomnia, lately I have myself not been able to get up in the morning on a regular basis which affects my sadhana and recently my wife got into a car accident because of lack of sleep due to her work pressures( fortunately she is ok).

So let’s start, what exactly is insomnia and what are its symptoms:

Difficulty falling or staying asleep, and/or waking up too early
A feeling of not getting enough sleep, including daytime fatigue or sleepiness
Inability to concentrate or forgetfulness
Irritability
Anxiety
Depression
Feeling preoccupied with symptoms, including aches and pains, in addition to the symptoms related to sleep

For many devotees, the symptoms of insomnia interfere with their personal relationships and job performance. It can affect Sadhana adversely and your ability to perform your services joyfully. In one survey, people who experienced sleep deprivation due to chronic insomnia had a two-fold increased risk of automobile accidents compared to people who were fatigued for other reasons.

CAUSES — The causes of insomnia vary from person to person. Causes of transient and short-term insomnia include:

Changes in the sleeping environment (the most common cause)
Jet lag due to travel across time zones
Work shift changes
Excessive noise
A room that is too hot or too cold
Stress, including the loss of a loved one, divorce, or job loss
Recent illness or surgery
Unresolved issues with devotees/spouse
Untreated pain
Strained relationships
Multiple thoughts racing in the mind

Jet lag is a common cause of disrupted sleep, resulting from crossing time zones and changing sleep schedules. Jet lag may occur regardless of the direction of travel (west to east or vice versa), although it is most pronounced when traveling west to east.

Chronic insomnia — The causes of chronic or long-term insomnia tend to differ from the causes of short-term insomnia. Psychiatric and psychological problems may be associated with chronic insomnia, and insomnia may develop before a person is diagnosed with a mental health problem.

Depression (especially among elderly people), anxiety disorders (including panic attacks, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder), and schizophrenia are psychiatric problems associated with sleep disturbances and chronic insomnia. In most people, insomnia is not caused by an underlying psychiatric or psychological problem.

Behavioral insufficient sleep syndrome — Insufficient sleep syndrome affects one third of adults, and it is estimated to be the most common cause of excessive sleepiness in the general population. With this, a person does not get enough sleep due to their lifestyle (like working two jobs or working while attending school) or because they are exposed to too much noise and light while trying to sleep. Missing an hour or two of sleep over an extended period can lead to daytime sleepiness, irritability, concentration problems, daytime performance problems at the job or school, muscle aches, or depression.

Inadequate sleep hygiene — Insomnia may also be related to poor sleep hygiene. Poor sleep hygiene refers to habits that interfere with a person's ability to fall asleep and stay asleep. Listening to loud kirtan or reading a new book or dealing with management issues might not be the best thing to do before going to bed.

Psychophysiologic insomnia — People with psychophysiologic insomnia have a chronic insomnia problem related to anxiety and increased tension at bedtime. About 15 percent of people who visit sleep disorder clinics have this type of insomnia. Patients do not have phobias, anxiety disorders, or other mental health problems, but they do feel very anxious and concerned about their sleep problems.

This disorder often starts in young adulthood and may begin with short-term insomnia. Eventually the person may become so excessively worried, fearful, and frustrated with not being able to sleep that he or she develops habits and responses that make getting to sleep and staying asleep very difficult.

Idiopathic insomnia — People with idiopathic insomnia, also known as primary insomnia, have had trouble falling or staying asleep their entire lives, often starting in childhood. This may result in problems functioning during the day, and clinicians think it may be linked to genetically determined abnormalities in the sleep-inducing or arousal systems. Patients with idiopathic insomnia often have family members with the condition.

Movement disorders — Movement disorders, including restless legs syndrome (RLS), are also a significant cause of insomnia. In restless legs syndrome, a person experiences an intense, creeping sensation in the lower legs that can only be relieved by moving the legs. This problem is worse while lying down in the evening and makes falling and staying asleep problematic.

Sleep apnea — Sleep apnea is the medical term for a condition that causes a person to frequently stop breathing during sleep, which may also cause insomnia. This is a very common yet undiagnosed problem, it poses serious health risks. Obesity is the single biggest risk factor.

Delayed sleep phase syndrome — People with this condition may not feel sleepy until very late, typically between 2:00 and 6:00 AM, and may have trouble awakening as early as they wish or must the next day (eg, to go to school or work).

Advanced sleep phase syndrome — This is the opposite of delayed sleep phase syndrome; a person goes to sleep in the early evening and wakes much earlier than they wish.

Rarely, some people have very irregular wake-sleep patterns that do not appear to respond to environmental cues

DIAGNOSIS

Sleep history — Insomnia can be diagnosed based on a patient or family's complaint, along with a careful evaluation of the sleep history. This would include a review of sleeping habits, medical, psychiatric, and neurologic illnesses, pain issues, and family history. A discussion with the bed partner or caregiver (to determine if the patient snores or breathes abnormally during asleep), and a review of the sleeping environment (to assess noise levels, the level of light, and temperature of the sleeping environment) is also important. A physical examination is needed to determine if there are medical conditions that may be causing or worsening the patient's sleep complaints.

A patient will be asked when their sleep problems began, as well as the duration, severity and frequency of these problems. Patients should also discuss how often they wake up during the night, whether they have trouble falling or staying asleep, and whether they have any trouble with mood or concentration during the day.

Sleep log — To help keep track of symptoms and provide more information about when they occur, the healthcare provider may ask a patient to complete a sleep log, usually over a two-week period. The patient should record information about their bedtime, how many times they got up during the night, how many naps they took, how long it took them to fall asleep, and how rested they felt upon awakening. A clinician may also use tests and questionnaires to help identify psychological problems, like depression, that could be related to the insomnia symptoms.

Laboratory testing — In addition to conducting a physical exam and taking medical and sleep histories, clinicians may use laboratory tests to help diagnose sleep disorders. However, this testing is not required for every patient with insomnia. These tests include:

Polysomnography (PSG) — Polysomnography is a formal sleep study done in a sleep laboratory or hospital. It uses monitors that are attached to the patient's body to record temperature, movement, brain activity, respiration, and other physiologic functions. This test may be used when a sleep-related breathing disorder is suspected, if a person has had insomnia for longer than six months and other medical conditions have been ruled out, or if the insomnia has not responded to treatment.

TREATMENT — Treating insomnia means diagnosing and treating the cause of the insomnia, such as restless legs syndrome or circadian rhythm disorders.

To treat idiopathic insomnia, or insomnia that is not linked to a specific medical condition, non-pharmacologic (not involving medication) and pharmacologic (involving medication) therapies may be recommended.

Behavioral treatments — Initial treatment for insomnia often include efforts to improve sleep hygiene. This may involve some of the following strategies:

Sleep only as much as is needed to feel rested
Go to bed when sleepy and try to get up at the same time each morning
Do not lie in bed for more than 20 minutes. If you do not fall asleep within 20 minutes, get out of bed and read or engage in a quiet and non-stressful activity until you are sleepy. Return to bed to sleep (see "Stimulus control" below).
Do not force sleep
Establish a regular bedtime and a regular wake-up time and stick to it, even on weekends
Use the bed only for sleeping
Avoid eating or drinking too much before bedtime, but do not go to bed hungry
Avoid daytime napping, especially in the late afternoon or evening.
Make the bedroom environment comfortable (consider light, noise, odors, bed partner)

Relaxation therapy — Relaxation therapy involves progressively relaxing the muscles from the head down to the feet, and maybe helpful for people who have difficulty "winding down". Relaxation therapy can also include imagery training, meditation, and self-hypnosis. A behavioral psychologist may be helpful for further training on relaxation therapy. Practicing yoga and listening to soft bhajans may also help.

Stimulus control — Stimulus control therapy is based on the idea that some people with insomnia have learned to associate the bedroom with wakefulness rather than sleep. This therapy teaches people to spend no more than 20 minutes trying to fall asleep. If the person cannot fall asleep within 20 minutes, they should get up, go to another room and read or find another relaxing activity until they feel sleepy again. This process is repeated until a person can fall asleep within 20 minutes.

Sleep restriction — Sleep restriction involves figuring the average total sleep time (not time in bed). The average sleep time should be a minimum of 5 hours. Patients spend only that amount of time in bed, with a rigid bedtime and wake time. This causes sleep-deprivation, increasing the need to sleep the next night. The sleep time can be increased by 15 minutes once per week.

Cognitive behavioral therapy — Cognitive behavioral therapy involves education about sleep needs, sleep expectations, and a discussion of anxiety and catastrophic thinking about sleep. The therapy works to replace these feelings or behaviors with thoughts that help the person fall asleep more easily. Several visits with a therapist may be needed, and the above-mentioned therapies may be discussed. For persons with chronic insomnia, cognitive behavioral therapy may be more effective than pharmacologic therapy for long-term improvement.

Medications — In addition to or instead of behavioral therapies, some clinicians recommend a medication for treatment of insomnia.

Although many people are concerned about becoming addicted to medications, this situation is not common. However, these medications tend to become less effective with long-term use. Thus, intermittent use of hypnotic medications may be recommended along with behavioral therapies.

Benzodiazepines — Benzodiazepines are a type of medication that cause sedation, muscle relaxation, and can lower anxiety levels. Most commonly prescribed medications are Xanax, Ativan or Valium, you need to discuss this with your doctor before you take these

Antidepressants/anti-anxiety medications — Antidepressants and antihistamines have been used for insomnia. However, these medications have a longer duration of effect than traditional hypnotics and can cause daytime sedation. Antidepressants are not thought to be helpful in managing chronic insomnia unless the patient also has untreated depression.

Over the counter sleep aids — Antihistamine medications (which are in over-the-counter sleep aids such as Nytol®, Sominex®, Unisom®, etc) cause sleepiness, but are not helpful in the long-term management or treatment of idiopathic insomnia. Benadryl is often helpful on a occasional basis.

Medications that contain an antihistamine and a pain reliever (eg, Tylenol® PM, Advil® PM) are not recommended unless a person has pain and difficulty sleeping.

Alternative treatments — A number of non-evidence based alternative treatments, including herbal products, homeopathy, and aromatherapy have been suggested as treatments for insomnia. Certain teas are very effective as well.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation. For more information, please check

National Sleep Foundation (www.sleepfoundation.org)

I hope this helps, if you still can’t sleep, try sitting up straight with head, neck, and body in straight line and chanting one round of Hare Krishna maha-mantra, that will certainly put you to sleep.

Your servant

Piyush Gupta, MD
gulla007@hotmail.com

Allergies( Aaaaachyuta)- Do you know what I am talking about??

I got inspired to write this article for our readers since I personally suffer from Seasonal Allergies and have struggled with it quite a bit. I also see devotees suffer from Allergies and loose sleep and work time and it can affect your sadhana and general sense of well being. SO let’s start with basics:

What are Allergies and how do they present themselves?

Occurrence of annoying nasal symptoms including discharge, itching, sneezing, congestion, and pressure. It is characterized by spells of sneezing, nasal discharge, nasal obstruction, and itching of the eyes, nose, and palate. It is also frequently associated with dripping on the back on your nose, cough, irritability, and fatigue . One might not get enough sleep and feel tired all the time.

Allergies are classified as seasonal if symptoms typically occur at a particular time of the year, or perennial if symptoms occur year round.

Nasal inflammation associated with allergic rhinitis can also predispose to bacterial infection of the sinuses. Symptoms of bacterial sinusitis may include nasal congestion, purulent nasal discharge or postnasal drip, facial or dental pain, and cough. Purulent nasal discharge, purulent postnasal drip, or pain in a maxillary tooth and persistent cough in children are the most useful predictors of bacterial sinusitis. \

How do I know I have allergies??? Diagnosis is made by history and examination, generally no specific tests are needed to make the diagnosis

Seasonal allergic rhinitis may commonly be diagnosed by the history alone. If allergen exposure is seasonal, tree and grass pollen in the spring (May-June, rose fever) or ragweed pollen exposure in the fall- (September or October,hay fever) are the most likely culprits, and the symptoms are predictable and reproducible

Similarly, episodic exposure to inhaled allergens such as cat salivary proteins, horse dander, murine urinary proteins, pollen, or house dust mite feces that may provoke acute allergic symptoms is easily diagnosed as episodic allergic rhinitis.

By comparison, classic perennial allergic rhinitis is associated with nasal symptoms which occur for more than two hours per day and for more than nine months of the year. Perennial allergic rhinitis usually reflects allergy to indoor allergens like dust mites, cockroaches, or animal dander, although aeroallergens may cause perennial rhinitis in tropical or subtropical climates.

What can I do to treat it and do I need to go to a doctor?

There are several things one can do:

1. The best thing is do avoid the allergens, grass, pollen and staying indoors or minimizing exposure to things which causes allergies.

2. One can take medicines as well. Medicines are classified into 2 broad categories, one is a nasal steroid spray and second is an anti histaminic medicine. Nasal steroids are generally safe and have no long term side effects even with chronic use. The most advertised in US is called Flonase and cost about $60-$80 per bottle. The three most common anti histaminic medicines for allergies are called Claritin, Zyrtec( both over the counter) and Allegra. All three have equal efficacy and depends upon what suits you best. Generic Claritin is available in Sams club or Walmart under the name Loratidine and costs only $11 for 150 pills. This is the cheapest treatment. I personally use Loratidine. You will also find Claritin D or Zyrtec D in the market, D stands for pseudoephedrine which is a decongestant- it increases blood pressure and its not recommended for long term use. There is another medicine called Singulair which is also very effective treatment for allergies.

3. Using Rose water( available in any Asian grocery store) for itchy eyes is very effective, use few drops 2-3 times a day. One can also purchase a medicine called Patanol eye drop solution, you will need a prescription for patanol and it’s considerably more expensive.

4. The most important thing is to start taking the medicines atleast 2 weeks before the allergy season hits you, because once it hits, it takes about 2 weeks for the medicine to kick in.

Do the medicines have any side effects?

The side effects of nasal steroids are mild and may include a mildly unpleasant smell or taste or drying of the nasal lining. In some people, nasal steroids cause irritation, crusting, and bleeding of the nasal septum, especially during the winter. These problems can be minimized by applying petroleum jelly (eg, Vaseline) to the septum before using the spray, using a saline nasal spray to restore moisture to the nasal lining, or switching to a water-based (rather than an alcohol-based) spray.

Studies suggest that nasal steroids are generally safe when used for many years. However, people who use these drugs for years should have periodic nasal examinations to check for rare side effects, such as nasal infection or ulceration. Anti histaminic medicines might give you a dry mouth or might make you a little drowsy

So, with this basic information , you should be able to protect yourself from allergies and be better prepared for the next sneeze(Aaaaachyuta).

For any questions, please don’t hesitate to write to me at gulla007@hotmail.com, or pgupta@colnhc.org

Your servant
Dr. Gupta

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Vanaprastha and Colonoscopy

Written by: Dr. Piyush Gupta, Columbus, Ohio (U.S.)
Submitted on Auguest 19, 2008

Age 50 is the time when you want to hang up your work boots and take time to rededicate your life and immerse yourself in spirituality, but before you do that and use the remaining wonderful years of your life to cultivate God consciousness and pass on the wisdom to posterity, an important medical decision awaits you.

Lots of devotees have questions about a test called a "colonoscopy," which is a screening test to look for colon (large intestine) cancer. One of my best friend's father is terminally ill with advanced stage colon cancer and recently another devotee was diagnosed with colon cancer.

Fortunately, it is preventable and there is a screening test available. Exactly what is it and what it entails can be found below. I recommend that all people should get a colonoscopy after age 50, if its negative, you do not have to worry about it for the next 10 years.

If you have no insurance, this test in the United States can cost anywhere between $1500-$2000. Medicare and medicaid pays for this test and hospitals might cover it under there financial assistance program called HCAP if you have no insurance.

If you have any additional questions related to colon cancer, colonoscopy, or any other health related questions, after reading the rest of this article, feel free to write to me at: pgupta@colnhc.org.

REASONS FOR COLONOSCOPY — The most common reasons for colonoscopy are to evaluate the following:

As a screening exam for colon cancer in anyone over age 50
Blood in the stool or rectal bleeding
Dark/black stools
Persistent diarrhea
Iron deficiency anemia (a decrease in blood count due to loss of iron)
Significant, unexplained weight loss, accompanied by gastrointestinal symptoms
A family history of colon cancer
To follow up an abnormal barium enema
A history of previous colon polyps or colon cancer
Surveillance in people with ulcerative colitis
For the medical management of chronic inflammatory bowel disease
Chronic, unexplained abdominal pain.

PREPARATION — The endoscopy unit will provide specific instructions about how to prepare for the examination. The instructions are designed to maximize safety during and after the examination, minimize possible complications, and allow the endoscopist to fully view the colon.

It is important to read the instructions ahead of time and follow them carefully; patients who have questions should speak with their healthcare provider or the endoscopy unit.

The inside lining of the colon must be cleaned of stool to permit the endoscopist to complete a thorough examination. This is accomplished by restricting what is eaten and by using purgatives.

What to eat — As a general rule, patients should not eat any solid food for at least one day before the examination. Only clear liquids (such as juices without pulp, bouillon, ginger ale) or clear gelatin (flavored is fine, but without added fruit) are recommended. The doctor's office or endoscopy unit will supply a list of fluids that are allowed.

Bowel emptying — There are two methods commonly used to empty the bowel of stool.

The first involves drinking a gallon of an undigestible solution (Go-Lytely®, and others) that causes temporary diarrhea. It comes in several flavors, which, unfortunately, only partially mask a somewhat unpleasant taste. Refrigerating the solution may make it more palatable. Drinking such a large volume of cold solution may cause a patient to feel chilled, but the sensation is temporary. Do not add flavoring to the solution. Many patients say that drinking the purgative solution is the most unpleasant part of the examination.

The second method involves drinking a solution called Fleet® Phosphosoda, along with several cups of liquid. This preparation is easier to consume than the purgative described above. However, the solution contains a large amount of phosphorus, which may be a problem for people with heart or kidney conditions.

Medications — Some medications, such as aspirin and iron preparations, should be discontinued for one to two weeks before the examination. Aspirin and pain killers such as ibuprofen (Advil®, Motrin®, Nuprin®) slightly increase the risk of bleeding. Patients who take a blood thinning medication (eg, warfarin [Coumadin®]) should consult with their clinician about when they should stop taking it.

Patients should also ask about medications for diabetes, heart or lung disease, high blood pressure, or seizure disorders. Some medications should not be stopped, and many of them can be taken before the examination.

Transportation home — Patients need to arrange for someone to escort them safely home after the examination. Although patients will be awake by the time of discharge, the sedative medications cause changes in reflexes and judgment that cause a person to feel well but can interfere with the ability to make decisions, similar to the effect of alcohol.

WHAT TO EXPECT — Prior to the endoscopy, a nurse will ask questions to ensure the patient understands the procedure and the reason it is planned. The nurse will ask questions to ensure the patient has prepared properly for the procedure. A doctor will also review the procedure, including possible complications, and will ask patients to sign a consent form.

The nurse will start an intravenous line (insert a needle into a vein in the hand or arm) to administer medications. The intravenous line insertion feels like a pin prick, similar to having blood drawn. The vital signs (blood pressure, heart rate, and blood oxygen level) will be monitored before, during, and after the examination. The monitoring is not painful. Some patients will be given oxygen during the examination.

THE PROCEDURE — The colonoscopy will be performed while the patient lies on their left side. Medications will be administered through the intravenous line. Most endoscopy units use a combination of a sedative (to help patients relax), and a narcotic (to prevent discomfort). Many people sleep during the examination while others are very relaxed, comfortable, and generally not aware of the examination.

The colonoscope is a flexible tube, approximately the size of the index finger. It has a lens and a light source that allows the endoscopist to look into the scope or at a TV monitor. The image on the TV monitor is magnified many times so the endoscopist can see small changes in tissue.

The endoscope contains channels that allow the endoscopist to obtain biopsies (small pieces of tissue), remove polyps and to introduce or withdraw fluid or air. Polyps are extra growths of tissue that can range in size from the tip of a pen to several inches (doctors measure them in millimeters and centimeters). Most polyps are benign (not cancerous) but can become cancerous if allowed to grow for a long time. As a result, they are usually removed so they can be analyzed. This does not hurt since the lining of the colon does not sense pain. (See "Patient information: Colon polyps").

Air is introduced through the scope to open up the colon so that the scope can be moved forward and to allow the endoscopist to see. Patients may experience a feeling of bloating or gas cramps from the air as it distends the colon. Try not to be embarrassed about releasing the air through the rectum; patients should let their physician know if they are uncomfortable

RECOVERY — After the colonoscopy, the patient will be observed until the effects of the sedative medication are gone. The most common discomfort after colonoscopy is a feeling of bloating and gas cramps. Patients may also feel groggy from the sedation medications. Patients should not return to work that day. Most patients are able to eat a regular diet after the examination. Patients should ask about when it is safe to restart aspirin or blood thinning medications.

COMPLICATIONS — Colonoscopy is a safe procedure and complications are rare, but can occur:

Bleeding can occur from biopsies or the removal of polyps, but it is usually minimal and stops quickly or can be controlled.

The colonoscope can cause a tear or hole in the tissue being examined, which is a serious problem, but, fortunately, very uncommon.

Adverse reactions to the medications used to sedate you are possible. The endoscopy team will ask about previous medication allergies or reactions and about health problems such as heart, lung, kidney, or liver disease.

The medications can cause irritation in the vein at the site of the intravenous line. If redness, swelling, or warmth occur, applying a warm wet towel to the site may relieve the discomfort. If the discomfort persists, notify the endoscopy unit.

AFTER COLONOSCOPY — Although patients worry about discomforts of the examination, most people tolerate it very well and feel fine afterwards. Some fatigue after the examination is common. Patients should plan to take it easy and relax the rest of the day.

The endoscopist can describe the result of their examination before the patient leaves the endoscopy unit. If biopsies have been taken or polyps removed, the patient should call for results within one to two weeks.

Your servant,
Piyush Gupta, MD

Insomnia

Allergies

Vanaprastha and Colonoscopy