Nibm History

[William Dupere]

Theuse of case studies has been integral to the pedagogic approach in training and teaching curriculums at NIBM. The Institute has a history of development and publication of case studies in various areas of banking and finance. Case studies have been developed on both an institutional basis as well as the self-driven activity of faculty. The Case Development Centre (CDC) at the Institute is facilitating case development by faculty to address the changing perspectives and challenges of the banking and finance industry.

Encircled by beaches and enriched by history, Sri Lanka is home to eight UNESCO World Heritage Sites. But beyond the beautiful coastlines, verdant landscapes and timeless ruins, this tropical isle has much more to offer for every kind of taste.

The NIBM has a legacy of almost five decades in the business of training and development. Its vision is to become the best institute in Sri Lanka that offers unmatched opportunities in management and IT education. Initially, NIBM started with the aim of enhancing the quality and productivity of Sri Lankan workforce through training and development.

Hiccups can be acute, lasting less than 48 hours, persistent, lasting over 2 days, or intractable, lasting more than one month. They can result from a variety of causes. In particular, hiccups are often caused by gastrointestinal disorders such as gastroesophageal reflux. Other causes include medication side-effects, cardiovascular disorders, central nervous system disorders, ear, nose, and throat disorders, psychogenic disorders, or metabolic disorders. Ths activity reviews the spectrum of hiccups from acute to intractable, outlines the causes, and offers recommendations for medical treatment based on clinical presentation. This activity stresses the role of the interprofessional team in the care of affected patients.

Objectives:Outline medications and medical conditions known to cause hiccups.Describe useful bedside maneuvers for aborting acute hiccups.Identify medical therapies for aborting persistent or intractable hiccups.Explain a well-coordinated interprofessional team approach to provide effective care to patients affected by persistent or intractable hiccups.Access free multiple choice questions on this topic.

The classification of hiccups is by their duration. Acute hiccups are of less than 48 hours duration, persistent last over 2 days, and intractable last over a month. As acute hiccups are self-limited and usually unreported, most of the research has focused on persistent and intractable hiccups. There are various causes of hiccups including organic causes, psychogenic, idiopathic, or medication-induced. Persistent and intractable hiccups may signify a more serious underlying etiology.

Gastrointestinal processes, particularly gastroesophageal reflux disease (GERD) and associated hiatal hernias, are implicated as the most common cause of acute hiccups.[3][4] The incidence of hiccups in GERD patients has been reported as high as 10%.[5] Distension of the stomach by large meals or carbonated beverages or irritation from spicy foods or alcohol are common associations. In patients with esophageal tumors, as many as one in four can present with persistent hiccups.[6] Similarly, overexcitement or anxiety, especially if accompanied by over breathing or air swallowing (such as with laughing fits), can trigger the hiccups reflex. [7]

Many drugs correlate with hiccups, especially alcohol. Some drugs, such as benzodiazepines, have a dose-dependent and an inverse relationship with hiccups. At low doses, benzodiazepines correlate with the development of hiccups. At higher doses, they may be useful in the treatment of hiccups. Chemotherapeutic agents and some glucocorticoids have shown a strong association with hiccups. Nearly 42% of patients taking both cisplatin and dexamethasone develop hiccups.[8][9] Other medications associated with hiccups include various chemotherapeutic agents, alpha-methyldopa and inhaled anesthetics.

First, the afferent limb is composed of the vagus nerve, the phrenic nerve, and the peripheral sympathetic nerves supplying the viscera. Second, the central processing unit likely involves the interaction between various midbrain and brainstem structures, such as the medulla oblongata and reticular formation, chemoreceptors in the periaqueductal gray, glossopharyngeal and phrenic nerve nuclei, solitary and ambiguous nuclei, hypothalamus, temporal lobes and upper spinal cord at levels C3 to 5.[9][20] Central neurotransmitters involved in this reflex include dopamine, gamma-aminobutyric acid (GABA) and serotonin.[20][26] Third, the efferent portion of the reflex is composed of the phrenic nerve supplying the diaphragm and the accessory nerves supplying the intercostal muscles.[20]

Hiccups commonly repeat at cycles of 4 to 60 per minute, depending on the individual. The diaphragmatic spasm is often unilateral, and the left hemidiaphragm is involved more than the right.[2] After diaphragmatic spasm, the reflex is completed by activation of the recurrent laryngeal nerve causing closure of the glottis. Without closure of the glottis, hyperventilation would occur.[20] Hiccups are inhibited by elevations in partial pressure of carbon dioxide (PCO2), vagal maneuvers, GABA-ergic agents (such as baclofen, gabapentin) and dopamine antagonists (such as chlorpromazine, haloperidol, metoclopramide) or agonists (amantadine).[26] Hiccups become persistent as a form of diaphragmatic myoclonus due to excess activity of the solitary nucleus of the medulla.[27][28]

Evaluating a patient with hiccups warrants a thorough medical history review. Ask about precipitating causes, such as large meals, excitement or emotional stress. Inquire regarding associated symptoms such as gastroesophageal reflux, coughing, weight loss, and abdominal pain. Ask about neurologic symptoms that might suggest a medullary stroke, multiple sclerosis or Parkinson's disease. Hiccups during sleep are uncommon and can occur with gastroesophageal, neurologic or pulmonary disorders, but negate psychogenic cause. Ask about recent surgery, known cancer or chemotherapy. A detailed medication review may identify a likely cause, and if discontinuing this offending medication provides significant relief then causality is confirmed.

In cases of persistent and intractable hiccups, one should investigate organic causes. A full HEENT evaluation may reveal processes such as a hair or foreign body pressing against the tympanic membrane, masses, goiters, tonsillitis, and pharyngitis. Listen to the lung sounds to assess for thoracic causes such as pneumonia or empyema. Palpate the abdomen for tenderness or mass to exclude obstruction, volvulus, pancreatitis, hepatitis or mass. A full neurological exam may expose CNS pathology such as strokes and tumors, though it is rare for hiccups to be the only presenting symptom.

Acute hiccups are typically benign and usually do not require a workup, however persistent and intractable hiccups should trigger a thorough evaluation to identify a treatable cause. It is reasonable to obtain lab work for evaluation of electrolyte abnormalities or to rule out infectious and neoplastic processes not identified on history and physical exam. Laboratory studies such as electrolytes, calcium, blood urea nitrogen (BUN), creatinine, lipase, and liver tests can be useful. A chest radiograph may identify intrathoracic sources of hiccups such as pneumonia, empyema, diaphragmatic hernia, adenopathy or aortic disease.[29]

The guiding of further imaging or interventions is best by the duration of hiccups, history and physical exam findings. For persistent or intractable hiccups associated with neurologic symptoms or signs, brain imaging by computerized tomography (CT) or magnetic resonance imaging (MRI) may demonstrate causes such as stroke, multiple sclerosis, tumor, syringomyelia, neuromyelitis optica, aneurysm or vascular malformation.[30] In rare cases, cerebrospinal fluid is necessary to exclude meningitis or encephalitis. For some cases, thoracic or abdominal CT imaging may identify cancer, aneurysm, abscess or a hernia. Referral to gastroenterology for upper endoscopy is essential to exclude lesions (such as esophageal cancer) in those cases of persistent hiccups refractory to initial antacid and proton pump inhibitor therapy.

It is essential to review blood gases in any ventilated patient that develops hiccups. Hiccups in ventilated patients may cause ventilator desynchronization, severe respiratory derangements, and hemodynamic changes.[31]

In the acute phase, hiccups are likely to be terminated by a variety of simple physical maneuvers supported by anecdotal evidence. Most of the maneuvers aim for some portion of the hiccup reflex arc. The frequency of hiccups decrease as PCO2 rises,[32] so Valsalva, breath holding, and breathing into a paper bag may be therapeutic. Supra-supramaximal inspiration is a technique where subject exhales completely, then inhale deeply and hold for 10 seconds, then without exhaling inhale two times again, each time holding for 5 seconds.[33] Other techniques include stimulation of the vagus nerve through the nose, ear, and throat by using cold drinks, pulling on the tongue,[34] pressure on the carotid, eyeballs or in both external auditory canals, sipping vinegar, swallowing sugar, stimulating the uvula or posterior nasopharynx (with smelling salts or nasal vinegar), Valsalva maneuver, and gargling, gagging or even self-induced vomiting.[7][35] More bizarre techniques reported have included sexual stimulation and digital rectal massage.[36][37] There are reports of suboccipital release and osteopathic/chiropractic manipulation techniques.[38][39] All of these techniques appear to be much more effective in the acute phase. The persistent phase is usually multifactorial and more difficult to treat.

Important steps in the treatment of persistent and intractable hiccups are, first, to assess whether the patient is using a medication known to induce hiccups, and second, to determine whether hiccups are associated with GERD. Discontinuation of an offending medication or use of an alternative agent (such as methylprednisolone instead of dexamethasone) can resolve medication-induced hiccups.[40] With as many as 80% of persistent hiccup cases related to GERD,[41][3] an initial therapeutic trial of antacids, antihistamines (such as famotidine) or proton pump inhibitor (such as omeprazole) may be successful,[42][41] and this approach has been suggested as first-line therapy.[7]

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