FOCUS In t e r n a t i o n a l Ho s p i t a l o f B a h r a i n Vo l . 3 I ss ue No . 3 4 W. L . L Sep te mbe r 2 0 1 3 SUSPENDED DOCTOR Suspension of a physician is a very serious happening in the life of a practitioner. No one should ever think of suspending a physician without involving the highest medical authority in the organization. Quite often the suspension has no justification whatsoever. Being suspended is dangerous and risky to the suspended physician. It carries a mortality of 2%, which is higher than that of open cardiac surgery. The mortality is due to two main causes. The first cause is suicide from depression. The second cause is stress-induced myocardial infarction. Death from suicide is twice that of myocardial infarction. Prolonged stress, anxieties, lack of sympathy and the accompanying dirty politics are heavy burdens for the professional physician to cope with. Stress piled on, day in, day out, night in, night out, going on, and on erodes the meaning of life and causes clinical depression. Quite often depression is masked and unnoticed. Everyone is shocked after the physician commits suicide. No one expected it. The hostility and lack of appreciation of the work of a dedicated physician are killers. They lower the doctor's self image and self esteem considerably. Add to all this the anxiety of future employment, financial implications, family problems arising from the suspension. The result is unbearable burdens on the mind of the Physician; burdens which are impossible to carry. The suspended physician often suffers ostracism; professionally and socially. It is most unfortunate that in our culture the competence of those who judge and suspend the Physician is often questionable. Myocardial infarction is four times more common in the suspended doctor than amongst his colleagues. The irony is that infarction is especially prevalent amongst the perfectionist physicians who pride themselves in their work. Obviously, suspension seems to hit them much harder than others. The worrier and the perfectionist physicians are two different types, who share a great deal of overlap. Both types need specialized psychiatric help, usually neglected. That is not all. Hypertension usually appears and gets worse. The depressed physician usually overeats. He may revert to alcohol. Many smoke a great deal. As if this is not enough; the suspended physician rewarded with a myocardial infarction, suffers the highest mortality rate of around 40%. It is sad that we as doctors do not have the proper defense conducted by respected senior physicians and specialists in the same field. An accused physician almost always, and rightly, feels abandoned. Physicians are their own worst enemies, because they sometimes tend to work against each other in their disciplinary matters. The practicing physicians must have their own professional defense organizations; as powerful bodies, respectable and authoritative. These organizations support the accused Physician morally, professionally and psychologically. The accused physician must receive professional psychiatric evaluation and constant support. The vulnerable doctor should be put on prophylactic aspirin, and his blood pressure and his health generally monitored. He must be kept well-informed about his condition, and treated with the courtesy he deserves. It is most important that all physicians realize how serious suspension is, and how demanding it is on all medical organizations. FOCUS Vol 3 - Issue No. 34 - September 2013 Editorial Team Honorary Editor: Dr. Faysal S. Zeerah Editor-In-Chief: Dr. Dilip Malhotra Editors: Dr. Nader Albert Ghobrial Dr. Mona Issa Farrag Dr. Ivo Fernandez Dr. Roland Mouawad Graphics and Design: Bryan Boter Published by: International Hospital of Bahrain, W.L.L. PO Box 1084, Manama Kingdom of Bahrain. Switchboard: +973 1759 8222 Email: health@ihb.net Website: www.ihb.net For Appointments, please call +973.17598200 How are we doing? We need your feedback for continuous improvement and want to hear from you. We welcome a letter or email detailing your patient care experience. Excellent, good, bad, indifferent, let us know how we are doing! We constantly strive to offer the best care and customer service and appreciate your feedback. Thank You. FOCUS is published as a service to the community. Although every effort has been made to ensure the accu-racy of information on this publication, the International Hospital of Bahrain cannot be held liable for any errors or omissions contained in this publication. Readers are advised to seek specialist advice before acting on information contained in this publication which is provided for general use and may not be appropriate for the readerвЂ™s particular circumstances. CONTENTS IHB NEWS 3 1st Paediatric International Conference 4 ACHSI Accreditation Success HEALTH FEATURES 5 Monitoring Under Anaesthesia 6 Gastric Bezoars 7 Behcet's Syndrome (Part 2 of 2) 8 Breast Reduction Surgery 9 Diaper Rash 10 Vaccination Myths and Facts 11 Bone Metastases 12 Myofascial Pain Dysfunction 13 Coronavirus 14 Malaria 15 Edema 16 Surgical Drains 17 Hydrocele 18 Health Related True Facts 02 CONGRATULATIONS TO ALL STAFF: FULL ACCREDITATION SUCCESS Monitoring Under Anaesthesia Surgical procedure under anaesthesia involves fluctuations in physiological parameters. The anaesthetist monitors the physiological variables for safe patient care during anaesthesia and surgery by assessing and recording the following : Circulation The circulation is monitored at frequent and clinically appropriate intervals by detection of the arterial pulse and supplemented, where appropriate, by measurement of arterial blood pressure. Ventilation Ventilation is monitored continuously by both direct and indirect means. Oxygenation Oximetric value is interpreted in conjunction with clinical observation of the patient. Adequate lighting is required to aid with assessment of patient colour. Monitoring Equipment The anesthetist responsible for monitoring the patient ensures that appropriate monitoring equipment is available. Visual and audible alarms are enabled at the commencement of anaesthesia. Depending on the type of anaesthesia, advanced monitoring is done in addition to basic mandatory ones. Oxygen Analyzer A device incorporating an audible signal to warn of low oxygen concentrations, correctly fitted in the breathing system, is kept in continuous operation for every patient when an anaesthesia breathing system is in use. Breathing System Disconnection or Ventilator Failure Alarm. When an automatic ventilator is in use, a monitor capable of warning promptly of a breathing system disconnection or ventilator failure is kept in continuous operation. Pulse Oximeter Pulse Oximetry provides evidence of the level of oxygen saturation of the hemoglobin of arterial blood at the site of application. This is kept in use for every patient undergoing general anaesthesia or sedation. Continuous Invasive Blood Pressure Monitor Continuous beat to beat variability of invasive blood pressure monitoring is done for major cases involving major fluid shift and also in cardiac patient requiring close monitoring. In most cases, this refers to a monitor connected via a transducer to an intra-arterial line. Carbon Dioxide Monitor (ETCO2) Carbon dioxide level is measured in exhaled gases whenever advanced airway is used, thereby ensuring intact airway and circulation. Volatile Anaesthetic Agent Concentration Monitor Equipment to monitor the concentration of inhalation anesthetics is kept in use for every patient undergoing general anaesthesia from an anaesthesia delivery system where volatile anaesthetic agents are available. Automatic agent identification should be available on new monitors. Temperature Monitor Equipment is used to monitor вЂњcoreвЂќ temperature continuously for every patient undergoing general anaesthesia. Neuro-muscular Function Monitor This is done for patients in whom a neuro-muscular blockade has been induced. Bispectral Index This is a technology to monitor the anaesthetic effect on the brain for use on patients at high risk of awareness during general anaesthesia. Monitoring is done in conjunction with careful clinical observation by the anaesthetist as there are circumstances in which equipment may not detect unfavorable clinical development. Electrocardiograph Equipment to monitor and continuously display the electrocardiograph (5-lead option) is used for every anesthetized patient. Intermittent Non-Invasive Blood Pressure Monitor Equipment to provide intermittent noninvasive blood pressure monitoring must be available for every patient undergoing anaesthesia. It comes in various cuff sizes. Visit our social media page Dr. Avijit S. Gaikwad Anaesthetist 05 Gastric Bezoars Gastric bezoars result from the accumulation of foreign ingested material in the form of masses or concretions. Bezoars are found in less than one percent of patients undergoing upper gastrointestinal endoscopy. TYPES Phytobezoars, composed of vegetable matter, are the most common type of bezoar. Trichobezoars, composed of hair, usually occur in young women with psychiatric disorders. Pharmacobezoars, composed of ingested medications, have become increasingly recognized. Bezoars composed of a variety of other substances have been described. These include milk curd, tissue paper, shellac, fungus, Styrofoam cups, cement, and vinyl gloves . PATHOGENESIS --- Bezoars grow by the continuing ingestion of food rich in cellulose and other indigestible materials such as hair, cotton, and tissue paper, matted together by protein, mucus, and pectin. Properties of the specific ingested material and some degree of gastric dysfunction also contribute. Bezoar formation is rare in healthy subjects. CLINICAL FEATURES Most adults with phytobezoars are men between the ages of 40 and 50 years, while trichobezoars are typically seen in women in their twenties . Affected patients remain asymptomatic for many years, and develop symptoms insidiously. Common complaints include abdominal pain, nausea, vomiting, early satiety, anorexia, and weight loss. Gastrointestinal bleeding is a common presentation since there is a high association of gastric ulcers in patients with bezoars who undergo surgery . The ulcers may be due to peptic ulcer disease or pressure necrosis. Although many bezoars become quite large, gastric outlet obstruction is an uncommon presentation. Other complications include gastrointestinal perforation, peritonitis, steatorrhea (excess fat in faeces), constipation, pancreatitis, intussusception (one portion of intestine sliding into the next), dysphagia (difficulty in swallowing), obstructive jaundice and appendicitis. DIAGNOSIS Bezoars are usually discovered as an incidental finding in a patient with nonspecific symptoms. Upper gastrointestinal endoscopy provides direct visualization of the bezoar and allows sample taking and therapeutic intervention. It is important to sample the bezoar for analysis since it may be difficult to determine the composition based upon appearance. TREATMENT Available treatment methods include chemical dissolution, endoscopy, and surgery. Phytobezoars may be chemically dissolved; in comparison, trichobezoars are resistant to enzymatic dissolution and must be removed with either endoscopy or surgery. PREVENTION Removal of the bezoar does not solve the underlying problem. Preventive therapy should be implemented to avoid a reported 14 percent recurrence rate . Patients should be encouraged to increase water intake and appropriately alter the diet . The physical examination is unremarkable in most patients with a gastric bezoar except for an occasional abdominal mass or presence of halitosis (bad breath). Visit our social media page Dr. Magdy Kamal General Surgeon 06 Behcet's Syndrome (Part 2 of 2) Epidemiology Behcet's disease is more common in eastern Asia to the Mediterranean. It is most common in Turkey (80 to 370 cases per 100,000) while the prevalence ranges from 13.5 to 20 per 100,000 in Japan, Korea, China, Iran, Iraq, and Saudi Arabia. The prevalence is similar in men and women in the areas where it is more common. It typically affects young adults 20 to 40 years of age but is infrequently also seen in children. Diagnosis New international criteria for diagnosis, published in 1990, require the presence of recurrent oral aphthae (small shallow painful ulceration) three times in one year plus two of the following in the absence of other systemic diseases: Recurrent genital aphthae. Eye lesions (anterior or posterior uveitis, cells in vitreous or retinal vasculitis). Skin lesions (erythema nodosum, pseudo-vasculitis, papulo-pustular lesions, or acneiform nodules. A positive pathergy test (skin prick test): a papule (small red bump) two mm or more in size developing 24 to 48 hours after oblique insertion of a 20 to 25 gauge needle 5mm into the skin, generally performed on the forearm). Prognosis Behcet's disease typically has a waxing and waning course. The disease appears to be more severe in young, male, and Middle Eastern or Far Eastern patients. Treatment Current treatment is aimed at easing the symptoms, reducing inflammation, and controlling the immune system. High dose Corticosteroid therapy is indicated for severe disease manifestations. Anti-TNF therapy such as Infleximab has shown promise in treating the uveitis associated with the disease. Another Anti-TNF agent (Enbrel), may be useful in patients with mainly skin and mucosal symptoms. Azathioprine (Imuran) when used in combination with interferon alfa-2b also shows promise. Colchicine can be useful for treating some genital ulcers, Erythema nodosum, and arthritis Thalidomide has also been used due to its immune-modifying effect. Interferon alfa-2a may also be an effective alternative treatment, particularly for the genital and oral ulcers. Visit our social media page Dr. Peter Farag Rheumatologist 07 Breast Reduction Surgery [Reduction Mammoplasty] Breast reduction surgery is performed to make the breasts smaller, as well as lift the breasts to a more youthful position. Back and neck pain, hunch back, rashes and skin irritation beneath breast folds, painful grooves on the shoulders from heavy bra straps, inability to exercise effectively or to participate in sports, agony shopping for clothes that fit and look proportional and unwanted attention are some of the torments that lead women with large breasts to seek Brest reduction surgery. For many people, large breasts indicate femininity and beauty. However, this is the not the case with women who suffer the symptoms of having excessively large breasts. Very large breasts can cause, in some women including adolescents, an enormous lack of self-confidence. If you are thinking of having more children probably it would be advisable that surgery is delayed until you have concluded this desire. Having children would affect and modify the results of your breast reduction due to changes that takes place during the pregnancy and breast-feeding. During the first consultation the plastic surgeon will evaluate the size and firmness of the skin, the most suitable breast shape and your general state of health as well. In some cases a mammography will be done. Surgery is performed under general anaesthesia. It takes between three to five hours. Patients stay in hospital for a couple of days. Marks are made on the skin according to the type of reduction planned. This is usually done before the patient is taken to the operating room with the patient in a sitting or standing position. Following surgery, suction drains are kept in the wounds to reduce swelling, bruising and blood clots. They are usually removed one to two days after surgery. Pain is controlled with medications. Patients are back to work in Relief from neck and back pain is often immediate for most women. approximately 10 days. The first menstruation after reduction can make the breasts Breast reduction is often described as the surgery that results in the swollen and painful. Scars are visible and permanent but most dramatic change in the body image. slowly fade over a period of six to 12 months. After the reduction, it is possible to experience temporary loss of sensation in the nipples. It takes several months before the breasts take on their final shape with a natural look and feel. Dr. Salil Bharadwaj Plastic Surgeon Visit our social media page 08 Diaper Rash Diaper rash A diaper rash is a skin rash that occurs anywhere in the area that is covered by a diaper. It is very common and can occur in any baby or child who wears a diaper. Causes The urine or bowel movement in the diaper which can irritate the skin. Diaper rash is especially common after a baby has diarrhea or has been on antibiotics. Perfumes or dyes in a diaper that a babyвЂ™s skin is allergic to. Skin conditions or infections that happen in the diaper area but are not caused by wearing a diaper. Symptoms Red, painful, or itchy skin Raised, peeling, or scaly areas Blisters If a babyвЂ™s diaper rash is caused by a skin condition or infection, the rash can be on other body parts, too. Treatment Diaper rash can be treated at home. Show the child to your doctor if: The rash gets worse or doesnвЂ™t get better after a few days of treatment. Your baby has diarrhea or a fever of 38В°C or more. Diaper rash is treated as follows: Take the diaper off to air out the skin as much as possible. Check your babyвЂ™s diaper every 2 or 3 hours, and change it when it is wet. Change your babyвЂ™s diaper right after each bowel movement. Put a skin ointment or paste on the area each time you change the diaper. Use a product that has Zinc oxide or Petrolatum in it. Use disposable diapers instead of cloth diapers. Most diaper rash go away after a few days. If the rash is severe or infected, your doctor might prescribe a medicine for you to use on the area. Prevention Change your babyвЂ™s diaper often. Clean the diaper area gently with warm water and pat the area dry with a soft cloth. Use unscented baby wipes without alcohol. Use a diaper ointment or paste on the area each time you change the diaper. Gently clean the area covered by the diaper with warm water and a soft cloth. If you use soap, use one that is mild and unscented. If the skin is peeling or sore, use a plastic squeeze bottle filled with warm water and then pat the area dry with a soft towel. Dr. Hesham Abdul Rahman Paediatrician Visit our social media page 09 Vaccination Myths and Facts Myth: Breast-fed babies donвЂ™t need to be vaccinated Fact: Breast-feeding can help protect your baby, but only for a short time. Vaccines can protect your baby for a long time, often for life! Myth: Many children get side effects with vaccines Fact: Severe side effects from vaccines are very rare, less than one in million! Getting the disease can be far more dangerous and painful. Myth: ItвЂ™s dangerous to give so many vaccines at the same time Fact: Giving several vaccines at one visit is safe and effective. Myth: Diseases are very rare now; vaccines arenвЂ™t really necessary Fact: Certain diseases are rare because of vaccines. If we stopped using vaccines, diseases would spread quickly, and many children would become very ill. Myth: Getting so many vaccines will overwhelm child's immune system Fact: It's safe to give a child simultaneous vaccines or multiple vaccine combinations, such as the six-in-one vaccine called Hexa vaccine, which protects against hepatitis B, polio, tetanus, diphtheria, pertussis (whooping cough) and Hib (Haemophilus Influenzae). Equally important, vaccines are as effective given in combination as they are given individually. Myth: As long as other children are getting vaccinated, mine don't need to be Fact: Skipping vaccinations puts the child at greater risk for potentially life-threatening diseases. The ability of immunizations to prevent the spread of infection depends on having a certain number of children immunized (Herd Immunity). The level of immunization required to prevent diseases such as measles from spreading from child to child is high -- 95 percent. Kids who are not immunized are at greater risk for disease; 22 times more likely to come down with measles. Myth: Vaccines cause autism Fact: There no evidence that vaccines cause autism. Many studies have shown the same risk of getting autism in MMR vaccinated and non-vaccinated children. Myth: Vaccines contain preservatives that are dangerous Fact: Thiomersal, an organomercury compound that prevents bacterial and fungal contamination of the vaccine contains Ethylmercury which does not pose the same health hazard as Methylmercury, a metal found in the environment that is known to cause brain development disorders. The body is able to eliminate Ethylmercury much more quickly than Methylmercury. Conclusion Vaccines are good. Vaccines save lives. Vaccine benefits far outweigh the pain and minor adverse effects. Dr. Mohamed El Biltagi Paediatrician Visit our social media page 10 Bone Metastases Bone metastases are the most common malignant bone tumours. After the lung and the liver, bone is the most common site of spread of cancers that begin in other organs. Metastasis in the bone occurs when cancer cells break off from a primary tumour elsewhere and enter the bloodstream or lymph vessels. Cancer cells can reach nearly all tissues of the body. It usually involves axial skeleton ie., skull, spine and pelvis where more red marrow is found. However, it is commonly seen in long bones and ribs. It rarely occurs distal to elbows or knees. 90% of bone metastases are multiple. Primary carcinomas (cancer) that frequently metastasize to bone are the breast, lung, prostate, kidney and thyroid. The first four comprises 80% of all metastases to bone. Symptoms Metastases to the lung and liver are often not detected until late in the course of disease because patients experience no symptoms. In contrast, bone metastases are generally painful when they occur. Symptoms are due to bone fractures, spinal cord compression, spinal instability, elevated calcium level in blood and anaemia (low hemoglobin). More than 50% of bone destruction suggests impending pathological fracture. Imaging Findings In general, metastases have little or no soft tissue mass associated with them. There is usually no periosteal reaction seen on X-rays. It may appear as moth-eaten (less defined margins), permeative (poorly demarcated) or geographic (well defined margins) lesions, indistinct zones of transition and no sclerotic margins. It may be expansile, soap-bubbly (septated), sharply circumscribed or have indistinct borders. Metastatic lesions are typically osteolytic (holes in the bone) from kidney and thyroid, osteoblastic (abnormal thickening or enlargement of bone) from prostate or mixed from lung and breast. No matter where the primary lesion is, skull metastases are usually lytic in appearance. Lytic metastatic lesions treated with radiation may look sclerotic. CT or MRI Scans are used to show findings in patients with negative conventional radiographs and/or positive bone scans. Treatment In many cases of bone metastases, the cancer has progressed to the point where multiple bony sites are involved. As a result, treatment is often focused on managing the symptoms of pain and bone weakness, and is not intended to be curative. Treatment options include radiation and medications to control pain and prevent further spread of the disease, and surgery to stabilize bone that is weak or broken. Bone scans are extremely sensitive but not very specific. 10-40% of lesions, not visible on plain films are positive on bone scans. Dr. Sagiraju Varma Radiologist Visit our social media page 11 Myofascial Pain Dysfunction Syndrome Myofascial pain syndrome is caused by tension, fatigue, or spasm in the muscles of mastication (chewing). This is the most common disorder affecting the Temporo-Mandibular region. The Temporo-Mandibular Joint itself is normal. However, it can also occur in the muscles of the neck and back. It is more common among women in their 20s and around menopause. Symptoms and Signs Symptoms include nocturnal Bruxism (excessive clenching of the jaw/grinding of teeth), pain and tenderness over the muscles or referred pain to other locations in the head and neck, and often, abnormalities of jaw mobility. Symptoms worsen if bruxism continues throughout the day. The jaw deviates when the mouth opens but usually not as suddenly or always at the same point of opening as it does with internal joint derangement. Exerting gentle pressure, the examiner can open the patient's mouth another one to three mm beyond unaided maximum opening. Diagnosis This is based on history and clinical examination. A simple test may aid the diagnosis: Two -three tongue blades are placed between the rear molars on each side, and the patient is asked to bite down gently. The distraction produced in the joint space may ease the symptoms. X-rays usually do not help except to rule out arthritis of the jaw joint. If temporal arteritis is suspected, ESR is measured. Treatment A plastic splint or mouth guard provided by the dentist can keep teeth from contacting each other and prevent bruxism. Low doses of a Benzodiazepine at bedtime are often effective for acute exacerbations and temporary relief of symptoms. Anti-inflammatory drugs and muscle relaxants may help some people. Patients must learn to stop clenching the jaw and grinding the teeth. Hard-to-chew foods and chewing gum should be avoided. Physical therapy, biofeedback to encourage relaxation, and counseling help some patients. Physical modalities include transcutaneous electric nerve stimulation and вЂњspray and stretch,вЂќ in which the jaw is stretched open after the skin over the painful area has been chilled with ice or sprayed with a skin refrigerant, such as ethyl chloride. Botox injection (Botulinum toxin) into the tense muscles also helps to relieve muscle spasm. The condition is often self limiting. Most patients, even if untreated, stop having significant symptoms within two to three years. Dr. John Meakkara Demtist Visit our social media page 12 CORONAVIRUS In the year 2012 and 2013 so far, 102 human infections with beta coronavirus were reported to the World Health Organization (WHO), of whom almost half have died. These occurred in Saudi Arabia, Qatar, Jordan, the United Arab Emirates, and the United Kingdom. Coronaviruses are the cause of up to one-third of community-acquired upper respiratory tract infections in adults and probably also play a role in severe respiratory infections in both children and adults. The human pathogens are classified into alpha and beta coronaviruses. They are RNA viruses and the name is derived from their characteristic crown-like appearance. COMMUNITY ACQUIRED CORONAVIRUSES Coronavirus related respiratory infections occur primarily in the winter, although infections can occur at any time of the year. Respiratory coronaviruses spread via direct contact with infected secretions or large aerosol droplets. Immunity develops soon after infection but wanes gradually over time, thus re-infection is common. CLINICAL MANIFESTATIONS Respiratory Human coronaviruses probably account for 15 to 20 percent of all acute upper respiratory tract infections in adults. They have also been linked to more severe respiratory diseases. They have been temporally linked to acute asthmatic attacks in both children and adults. They have been found in variable proportions, ranging from 2 to 8 percent, of neonates, infants, and young children hospitalized with community-acquired pneumonia, and have been identified even more frequently in lower respiratory tract disease in outpatients. They are also an important cause of nosocomial infections in neonatal intensive care units. Among elderly patients, there is increasing evidence that coronaviruses are important causes of influenza-like illness, acute exacerbations of chronic bronchitis, and pneumonia. Enteric Both HCoV-HKU1 and HCoV-OC43 (Types of Corona Viruses) have been found in infants hospitalized with diarrhea (often with respiratory symptoms as well). DIAGNOSIS Diagnosing SARS-CoV (Severe Acute Respiratory Syndrome Coronavirus) is important for understanding outbreak epidemiology and limiting transmission of infection. Until recently, no sensitive, rapid method existed to detect all of the known human coronavirus strains, as community-acquired coronaviruses are difficult to grow in tissue culture. Various respiratory specimens (eg, sputum, tracheal aspirates, broncho-alveolar lavage fluid, naso-pharyngeal swabs or aspirates) should be sent for testing. The WHO recommends that the following persons should be evaluated epidemiologically and tested for coronavirus: A person with an acute respiratory infection, and evidence of pulmonary parenchymal disease (eg, pneumonia or the acute respiratory distress syndrome [ARDS]), who requires admission to hospital, plus any of the following: The disease occurs as part of a cluster that occurs within a 10-day period. The disease occurs in a health-care worker who has been working in an environment where patients with severe acute respiratory infections are being cared. The patient develops an unexpectedly severe clinical course despite appropriate treatment. TREATMENT AND PREVENTION There is currently no treatment available for coronavirus infections except for supportive care as needed. Several antiviral and other agents were used during the SARS outbreak but the efficacy of these drugs has not been established. Preventive measures consist of hand washing and the careful disposal of materials infected with nasal secretions. Visit our social media page Dr. Ehsan Sabry Pulmonologist 13 MALARIA Malaria is a disease caused by an infection with a parasite. Mosquitoes carry the parasite and spread it to people by biting them. Malaria is common in many countries. It can be mild to severe. Severe malaria can cause serious health problems and even death. Symptoms Common symptoms include fever, chills, sweating, headache, body ache, tiredness, gastro-intestinal problems (loss of appetite, nausea or vomiting, pain in the abdomen, diarrhoea), jaundice, cough, fast heart rate or breathing. Severe malaria can cause confusion, seizures (fits) and dark or bloody urine. You should consult a doctor if you get a fever while you are traveling or after you come back. Be sure to tell your doctor where you traveled, including any airports where you changed flights. Investigations Blood test is done to look for the parasite that causes it. There are several different types of the parasite. If you have malaria, the doctor needs to know the type to start the right treatment. A blood test can also show if malaria is causing other health problems. Treatment There are several different medicines. Some people need to take more than one. Most people can be treated at home with oral medications. People with severe malaria need treatment in the hospital. Medicines are given intravenously (through a thin tube into a vein). After initiation of treatment, blood tests are repeated every day for a few days. The tests are to ensure that the medicines are working. Prevention If you travel to an area where malaria is common, taking medicine can help prevent infection. Taking malaria medicine is important even if you travel to a place where you used to live and are going back to visit friends or relatives. Wearing shoes, long-sleeved shirts, and long pants when you go outdoors. Wearing bug spray or cream that contains DEET (N, NDiethyl-meta-toluamide) or a chemical called Picaridin. Sleeping in a building with good screens over the windows and doors and air conditioning. Using a mosquito net. You can also reduce your risk by preventing mosquito bites by: Staying indoors at night Dr. Hady Mohammed Gad Internist Visit our social media page 14 EDEMA Edema is the medical term for swelling caused by a collection of fluid in the small spaces that surround the body's tissues and organs. Some of the most common sites are: The lower legs or hands (Peripheral edema) Abdomen (Ascites) Chest (Pulmonary edema if in the lungs and Pleural effusion if in the space surrounding the lungs) Ascites and peripheral edema can be uncomfortable and can be a sign of a more serious condition. Pulmonary edema is a symptom of heart failure which can be life-threatening. Symptoms of edema may include: Swelling or puffiness of the skin, causing it to appear stretched and shiny. This typically is worse in the areas of the body that are closest to the ground (because of gravity). Therefore, edema is generally the worst in the lower legs after walking about, standing, sitting in a chair for long periods. It also accumulates in the lower back (sacral edema) after being in bed for a long period. Pushing on the swollen area for a few seconds will leave a dimple in the skin. Increased size of the abdomen (Ascites). Shortness of breath (with edema in the chest). A number of different conditions can cause edema: A common cause of edema in the lower legs is chronic venous disease, a condition in which the veins in the legs cannot pump enough blood back up to the heart because the valves in the veins are damaged. This can lead to fluid collecting in the lower legs, thinning of the skin, and, in some cases, development of skin sores (ulcers). Edema can also develop as a result of a blood clot in the deep veins of the lower leg (called deep vein thrombosis [DVT]). The edema is mostly limited to the feet or ankles and usually affects only one leg. Edema in women that occurs during monthly menstrual periods can be the result of hormonal changes related to the menstrual cycle. This does not require treatment as it resolves on its own. Drugs: Edema can be a side effect of a variety of medications, like oral diabetic, high blood pressure medications, anti-inflammatory drugs and estrogens. Kidney disease: The edema of kidney disease cause swelling in the lower legs and around the eyes. Heart failure: also called congestive heart failure can cause swelling in the legs, abdomen and pulmonary edema. Liver disease: Cirrhosis is scarring of the liver from various causes, which can obstruct blood flow through the liver. People with cirrhosis can develop pronounced swelling in the abdomen (Ascites) or in the lower legs (Peripheral edema). Travel: Sitting for long periods, such as during air travel, can cause swelling in the lower legs. This is common and is not usually a sign of a problem unless it remains swollen for days or if leg becomes painful (sign of DVT). Pregnancy: Swelling commonly develops in the hands, feet, and face, especially near the end of a normal pregnancy. Swelling without other symptoms and findings is not usually a sign that a complication, such as pre-eclampsia, has developed. Visit our social media page Dr. Nader Ghobrial Nephrologist 15 Surgical Drains A surgical drain is a tube used to remove pus, blood or other fluids from a wound. Drains inserted after surgery do not result in faster wound healing or prevent infection but are sometimes necessary to drain body fluid which may accumulate and in itself become a focus of infection. Indications for drain insertion To eliminate dead space. To evacuate body fluids (pus, blood, bile) or gas. To prevent potential accumulation of fluid or gas. To form a controlled fistula e.g. after common bile duct exploration Classification of drains Open or Closed Drains: Open drains include corrugated rubber or plastic sheets. Drained fluid collects in gauze pad or stoma bag. There is higher risk of infection. Closed drains consist of tubes draining into a bag or bottle. They include chest and abdominal drains. The risk of infection is less. Active or Passive drains: Active drains are maintained under suction. They can be under low or high pressure. Passive drains have no suction. It drain by means of pressure differentials, overflow, and gravity. Chest Tube: used as closed system under water seal to drain blood, fluid or air from the lungs (pleural space Types of Drain Jackson-Pratt drain is a drainage device used to pull excess fluid from the body by constant suction. A pigtail drain tube (pigtail) is a type of catheter that has the sole purpose of removing unwanted body fluids from an organ, duct or abscess. A Penrose drain consists of a soft rubber tube placed in a wound area, to prevent collection of fluid. Redivac drain: a fine tube. with many holes at the end, which is attached to an evacuated glass bottle providing suction. It is used to drain blood beneath the skin, e.g. after removal of breast and thyroid, or from deep spaces. Corrugated rubber drains are used either for the wound or for deep drainage. The drain is fixed by a suture at the end of the wound to prevent the drain slipping inwards. Negative pressure wound therapy involves the use of enclosed foam and a suction device attached. This promotes faster tissue granulation, often used for large surgical/trauma/non-healing wounds. Removal of Drain Generally, drains should be removed once the drainage has stopped or becomes less than 25 ml/day. Drains can be 'shortened' by withdrawing by approximately 2 cm per day, allowing the site to heal gradually. Drains that protect post-operative sites from leakage form a tract and are usually kept in place for one week. Kehr's T tube: a tube consisting of a stem and a cross head (thus shaped like a T). The cross head is placed into the common bile duct while the stem is connected to a small pouch (i.e. bile bag). It is used as a temporary postoperative drainage of common bile duct. Dr. Ahmed El Sakka General Surgeon Visit our social media page 16 Hydrocele Hydrocele is a collection of fluid inside the scrotum. The scrotum is the skin sac that holds the testicles, so hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis, the investing layer that directly surrounds the testis and spermatic cord. It is the same layer that forms the peritoneal lining of the abdomen. Hydroceles are believed to arise from an imbalance of secretion and re-absorption of fluid from the tunica vaginalis. Vas Deferens Hydroceles are common in newborn baby boys. It usually disappears by the time the baby is one year old. Older boys and adults, usually over the age of 40 years can also get hydrocele. The cause is not known in most cases. A small number of hydroceles are caused when something is wrong with one of the testicles (testes). For example, infection, inflammation, injury or tumours of a testicle (testis) may cause fluid to be formed leading to a hydrocele. Sometimes hydroceles develop when there is generalised swelling of the lower half of the body due to fluid retention. Hydrocele usually does not cause symptoms, except when it gets very large. When it does, the symptoms can include: Epidydimis Pain or discomfort in the scrotum Feeling as though the scrotum is heavy or full Testis Swelling or irritation in the skin around the scrotum Diagnosis Hydrocele Light test: by shining a powerful light on the area of the scrotum where there is a swelling. If the light passes through, it means there is nothing solid blocking the light as fluid does not block the light. Ultrasound: This test uses sound waves to create pictures of the inside of the body. An ultrasound usually confirms the presence of fluid and excludes any other condition. Treatment Treatment depends on what caused the hydrocele, symptoms, age of patient and type of hydrocele. Although hydroceles can be drained with a needle, recurrence is common. Surgery (Hydrocelectomy) to remove the fluid and eversion of the sac that holds it, is a simple procedure and usually curative Dr. Yousry Hanna Urologist Visit our social media page 17 Health Related True Facts http://www.funny2.com/health.htm The safest number of times to reuse a disposable razor is only 3. Disposable razors have thinner blades than other razors, and are thus more prone to producing microscopic cuts in the skin. The longer you keep using a disposable razor, the more germs it will collect, and the greater the chance that a nick will become infected. When you walk uphill, the level of harmful fats in the bloodstream goes down. When you walk downhill, blood sugar levels are reduced. Alter your patterns of exercise depending on your health needs! 90% of the calories in cream cheese come from fat! It's the most fattening cheese. Make sure your television set is securely supported if you have young children in your house. At least 28 kids were killed by toppling television sets in 1997. If you have an impaired immune system, don't eat alfalfa sprouts. Some sprouts have caused outbreaks of E. Coli and salmonella! Coffee does not increase the risk of heart attacks. A recent study showed that even 4 or more cups daily didn't increase heart attack risk. Sweet potatoes contain no more calories than white potatoes, and virtually no fat. Watch out for cars turning left at traffic lights! A high proportion of accidents (with other cars or pedestrians) involve a left-turning vehicle! If you order a shake at a fast food restaurant, the good news is: a 16 ounce shake provides about 400 mg of calcium. The bad news: it also supplies about 400 to 600 calories and at least 9 grams of fat! Measure your waist to find out if you are at risk for weight-related health problems. For women, a waist measurement of 34 1/2 inches signals a serious risk. For men, the cutoff point is 40 inches. Watch out! Grapefruit juice can greatly boost the concentration of certain drugs in the bloodstream. These include some popular cholesterol-lowering drugs, calcium channel-blockers, tranquilizers and some antihistamines. If you drive with a small child in your car, make sure you use the child safety seat properly! Only about 60% of children age 4 or younger ride in such seats! In addition, 80% of these safety seats are improperly used. Per-capita Mozzarella cheese consumption has risen five-fold since 1972. Mozzarella is the second most popular cheese, next to cheddar. As people age, they burn fewer calories. This often results in increased body fat and loss of muscle. All it takes, however, is a brisk 2 mile walk daily to balance energy intake and energy needs. If you have symptoms of a heart attack, such as chest pain, chew and swallow one adult aspirin tablet (325 mg) immediately, while you seek medical help. If you have only baby aspirin at home, chew four of them. The number one vegetable in the US is the potato. Per capita consumption is 84 pounds each year! One third of those end up as french fries. 5% are in the form of potato chips. Knuckle cracking does NOT cause arthritis, enlarged joints or any other harm. It's just irritating to some people. Many studies show that married people tend to be healthier than unmarried ones. One theory is that being married encourages healthy behavior, such as wearing seat belts, being physically active and having blood pressure checked. Visit our social media page 18