Poisoning

Suicidal or homicidal poisoning with drugs over dosage is one of the common causes of morbidity and mortality in Asian countries. Acute poisoning accounts for an estimated 10-20% of acute medical admissions in United Kingdom.

When a patient with poisoning is bought to the ward, the following management steps are carried out.

·         assessment of the danger

·         gut decontamination using  activated charcoal

·         maintenance of fluid balance

·         air way control

Gastric levage is important if could be performed within first 60 minutes of ingestion of poisons. In some of the developing countries gastric lavage is carried out even after 2 hours. This is an incorrect method. In those countries the procedure is carried out by non medical personell with no training. This should never be happened. It put the patient’s life in danger due to aspiration.

Gastric larvage should never be performed on patients who does not give consents to do so.

MANAGEMENT

The following should be done in patients who present with a history, signs and symptoms of poisoning.

I)                    General Management

a.      Securing the airway, intubation,

b.      Assessment of breathing, oxygen saturation, and arterial blood gas analysis

c.       Circulation should be assed by measuring pulse rate, blood pressure, urinary output and peripheral perfusion

d.      estimate S. electrolytes, S. glucose and other parameters

e.      Challenge with glucose should be done to avoid irreversible brain injury due to hypoglycemia.

II)                   Specific Management

Gall Stones

Abdominal Pain?gallstones?signs & Symptoms? http://ehealthcom.blogspot.com/2010/12/abdominal-pain-is-it-gallstones-what.html

Gall stones Cholecystectomy  http://ehealthcom.blogspot.com/2010/12/cholecystectomy.html

Cholecystectomy  http://ehealthcom.blogspot.com/2010/12/cholecystectomy.html

Hepatitis

Hepatitis http://ehealthcom.blogspot.com/2010/12/hepatitis-treatments.html

Hepatitis B? What are the treatments? http://ehealthcom.blogspot.com/2010/12/hepatitis-b-what-are-treatments.html

Hepatitis B Vaccine http://ehealthcom.blogspot.com/2010/12/hepatitis-b-active-immunization-vaccine.html

Hepatitis C Sexual Transmit? http://ehealthcom.blogspot.com/2010/12/is-hepatitis-c-virus-transmitted-by.html

Hepatitis B? What are the treatments?

The disease caused by Hepatitis virus can be acute, chronic inactive or chronic active. The treatment differs according to the state of the disease.

If you have acute hepatitis B virus infection, then specific treatment is given for the disease. Some people become very anxious when they are not given any treatment, but they have to understand that it is the best treatment for the disease. Let me explain why.

Like in many other viral diseases, hepatitis B infection is also a disease caused by a virus. In many of the viral diseases we can’t do much to destroy the virus. There are several drugs that have been shown results, but the best way is to let the body fight against it by it self. So all we have to do is give our bodies the optimum condition to fight, so it does not have to spend energy on other things. That’s why the treatment for acute illness is rest and symptomatic treatment. So the body finally develops immunity against the virus and become resistant.

On the other hand the people who develop chronic illness are the once who were unable to fight against the virus successfully. So the virus persists in their bodies causing continuous damage to the liver finally causing cirrhosis and hepatocellular carcinoma. Therefore, such patients are given medications like interferon to kill the virus.

Hepatitis – Treatments

If Hepatitis is due to an infectious cause, the treatment varies according to the infecting viral agent.

Hepatitis A 

Usually there is no specific treatment carried out for hepatitis A. Corticosteroids, rest and dietary measures have no proven effectiveness in relieving the disease. The disease persist for several weeks and wears off on its own. 

Even though hospital admission is not requires, because the patient can recover on its own, many physicians tends to keep the patient under observation even after recovery. This is because that some people often develop another attack of hepatitis in rare instances.

If the patient develops fulminant hepatitis, it can be so severe enough to cause death.

Hepatitis B

The disease could be acute or chronic.

Acute Hepatitis – 

The treatments are often symptomatic, but antiviral therapy is started for symptomatic patients, but the efficacy of the treatment is still unknown.

Some specialist thinks that HBeAg positive patients should be treated with neucleoside analogues for 12 months. 

Chronic Heptitis –

These patients are treated with following antivirals.

• ·         Interferon

• ·         Lamivudin – Monotherapy is not recommended.

• ·         Adefovir – More effective than LAmivudin.

                                 Reduces HBV DNA more quickly
                                 Less virus resistance

• ·         Entacavir

• ·         Tenofovir  - Effective against lamivudin resisitant viruses.

In general C Hepatitis is treated with pegylated interferon or tenofovir

Hepatitis D

The patients are treated with pegylated alpha-29 interferon for 12 months duration, but the response id very poor. Lamivudin and adefovir are also not effective.

Hepatitis C

They are usually given a combination of pegylated interferon and ribavirin. The efficiency of the treatment will depend on the viral load.

References:

Kumar and Clark’s Clinical Medicine 7^th Edition

Is Hepatitis C virus transmitted by Sexual intercourse?

Hepatitis C virus is known to transmit through blood and blood products.  The high prevalence of the disease among patients who take intramuscular vaccination supports this finding.

There is a high prevalence of the disease in Egypt as a result of parenteral antimonial treatment.  Therefore, more contact with needles, greater the chance of getting the disease. 

Surprisingly the disease prevalence among homosexual and bisexual people and prostitutes is lower than that of intravenous drug users, indicating the lesser chance of acquiring the disease by unprotected sex. 

References:

Kumar and Clark’s Clinical Medicine 7^th Edition

Gastric Carcinoma

Gastric carcinoma has a high prevalence in Japan and a certain parts of China. In one area in China, it is found to be twice more prevalence than that in Japan. The disease prevalence in west is several times lower in western countries. The disease rate is also low in Japanese People who live western countries indicating an environmental association.

Due to its high prevalence, Japan has started a screening program to detect gastric cancer at early stages. The earlier we detect the cancer better the outcome. Screening in other countries is not cost effective because only few people will have the illness. Therefore it is not carried out effectively in any other country other than Japan. Due to this lack of screening programs the patients with gastric carcinoma present with end stage disease. 

The disease can be treated effectively if the disease is detected at early stages (there is no haematogenous spread, there is no involvement of irremovable organs). In these cases surgical resection of involved parts are carried out.

References:

Bailey and Love’s Short Practice of Surgery 25^th Edition

Kumar and Clark’s Clinical Medicine 7^th Edition

Cholecystectomy

Cholecystectomy means the excision of the gallbladder.

Cholecyctectomy is the treatment of choice for cholecystitis. Even though some physicians would like to manage the patient conservatively, many think it is appropriate to do the surgery as early as possible to reduce the risk of recurrence. 

If the disease recurs, the symptoms may become worse and the patient may deteriorate fast. Therefore, the surgery is usually done within first 48 hours. 

Now with advancement of the laparoscopic surgeries, the first choice of removal of gallbladder is by a laparoscopic cholecystectomy. It was earlier done by laperotomy and it is still being used when laparoscopic surgery is unavailable and when any complication arise during laparoscopic cholecystitis. 

Complications of cholecystectomy

·         Bile duct injury

·         Bleeding

·         Wound infection

·         Hypertrophic scar

·         Keloid

·         Burst abdomen

·         Incisional hernia

·         Deep vein thrombosis

·         Post cholecystectomy syndrome

This is said when the symptoms persist even after the surgery. It is mainly due to wrong diagnosis.

References:

Kumar and Clark's clinical Medicine Seventh Edition

Bailey and Love's Short Practice of Surgery 25th Edition

Hepatitis B Active Immunization (Vaccine)

As Hepatitis B infection can cause severe liver disease including cirrhosis, hepato-cellular carcinoma and chronic liver disease, all at risk personnel should have protection against it.

Hepatitis B virus is transmitted through blood, blood products and body fluids. Therefore people who regularly get contact with these should be vaccinated against the virus. They are,

• Health care personnel
• Emergency and rescue service personnel
• Embalmers
• Morticians
• Children

This is done by giving active immunization. The vaccine is produced by integrating the hepatitis B surface antigen gene in to yeast. It is given in 3 doses. The second is given 1 month after the first dose and the second 6 months after. It is given to the deltoid muscle. It is capable of producing a short term protection in over 90% f the people.

The vaccine may not produce enough antibodies in,

• People older than 50 years of age
• Severely ill patients
• Immunocompromised people like HIV/ AIDS

So these people should be given larger doses more frequently.

The antibody levels should be checked in all the risk groups at 7-9 months after the initial dose.

The antibody levels slowly declines over time, so a booster dose to increase the antibody levels should be given 3-5 years after the initial dose.

There are some mild side effects that can occur rarely. There include fever, rash and soreness over the injection site.

References:

Kumar and Clark’s Clinical Medicine 7^th Edition

Abdominal Pain? Is it gallstones? What are the signs & Symptoms?

If you have abdominal pain, it could be due to gallstones, but there are docents of other diseases which may cause abdominal pain. Therefore, a thorough analysis of your symptoms should be done followed by examinations and investigations to establish the diagnosis of gallstones.

Gallstones can be found in following places. The symptoms vary according to the place where the gallstones are. 

·         Gallbladder

Gallbladder is the organ which acts as a reservoir of bile secreted by the liver. It also concentrates bile by active absorption of water.  

Majority of patients who have stones in the gall bladder do not show any symptoms. The diagnosis is usually incidental in such cases.

They start showing symptoms once they develop any of the following conditions.

o   Acute cholecystitis

The gallstones in the gallbladder can migrate in to the cystic duct and thereby obstruct the bile outflow from the gallbladder. In such situations the gallbladder wall contracts forcefully to overcome the obstruction.

So the patient experiences billiary colic. So you may experience pain over the upper right side of the abdomen. It starts recently, and the pain is very high. The pain is persistent and may radiate to the tip of the right shoulder and to the right infrascapular region.

Usually the pain is relieved by pain killers. You may also have vomiting, and low grade fever.

The right upper abdomen is painful to touch.

o   Empyema of gallbladder

o   Emphysematous cholecystitis

o   Perforation and billiary peritonitis

o   Chronic cholecystitis

o   Mucocele of the gallbladder

o   Carcinoma of the gallbladder

It is not necessary that each and every patient may finally develop any of the above conditions. Some people may live with no symptom or complication even they have gallstones.

·         Common bile duct

You may have acute onset, persistent sever epigastric pain radiating to the right upper abdomen, tip of the shoulder and right infrascapular region. You may also experience vomiting. The pain is relieved with pethidine.

Your eyes will become deeply yellowish. You may have fever with chills and rigors.

·         Pancreatic duct and terminal Ileum are other places where gallstones could be present.

More : Cholecystectomy

References:

Bailey and Love’s Short Practice of Surgery 25^th Edition

Kumar and Clark’s Clinical Medicine 7^th Edition

Do you have Headache? What Might be the Cause?

Headache is a common symptom of most of the neurological diseases involving the brain. Some of these caonditions can be fatal and accurate identification of the cause of headache is essential.

So if you have headache, first you should see what kind of a headache that is, because the nature of the headache differs with the type of underlying pathology.

Are you having headache for a long period (from months to years)? Does it reccurs occasionally?

 Then it could be due to following causes.

 The most common cause for this kind of headache is migraine. Migraine is not a serious condition and nowadays there are more successful treatments for this condition.

 Glaucoma and sinusitis can also cause recurrent attacks of headache.


Does your headache aggravates when you cough, strain, sneeze, walk or lie down?

 Then you could be having any of the following conditions.

Brain tumour - in this type of headache you may also have vomiting as an associated feature.

Headache which gradually rises within days to weeks

Brain Tumour
Encephalitis
Meningitis

Headache with tenderness (pain when touching) of the scalp

giant cell arteritis

Pain after injury to the head

Most of the times these kinds of headache does not indicate any serious pathological condition, but subdural haematoma should always be considered.

Single attack of severe headache

Subarachnoid haemorrhage
migraine
meningitis

Joint Pain and Swelling? Rheumatoid Arthritis?

Today I met a patient who has had and still having multiple joint pain and swelling for more than 20 years duration. She was 44 years now and is suffering from sero positive rheumatoid arthritis since childhood. Despite her present day condition with all the pains, aches and disabilities, she was surprisingly quite happy and active.

She has first started experiencing right knee pain which was very mild initially. Then  the pain has gradually increased in severity. The mild pain has been there for nearly an year, and she had not look for medical advice since it was not unbearable.

But the things began to get worse after about one year. By that time, both her knees were swollen and painful and the same kind of symptoms has started to appear in all joints in her body.

For the past 25 years the arthritis condition relapses and recurses. Her X-Ray revealed severely reduces bone densities. Her condition was kept under control by medication for about 15 years, but unfortunately her condition has started worsening recently.

Recently, her mobility has reduced due to severe hip, knee and back pain. As a result she has started to develope joint deformoties, due to lack of exercise. Therefore her doctors had decided to  do a hip replacement and knee replacement. Both the surgeries were successful and now she says that she is not experiencing any pain in those replaced joints.  This is good news for people who are awaiting joint replacement as a treatment method for rheumatoid arthritis.

This is a more severe form of rheumatoid arthritis. Not all the rheumatoid arthritis patients develop same kind of illness. Some people may experience only one episode of joint pain and the illness never occurs gain in their lives again.

Have you got joint pain and swelling? How to know whether it is actually rheumatoid arthritis.

People with following properties are more likely to have Rheumatoid arthritis.

• Female gender
• Age 30-50 years
• The following pattern of joint involvement

Gradually rising moderate joint pain. If the disease has taken several months to years, to reach its maximum condition, you are more likely to have rheumatoid arthritis.  

• Symmetrical joint involvement – This means the bilateral involvement of the joint.

The peripheral joints are commonly involved (peripheral poly-arthritis)
 

• Stiffness of the joints - Commonly this is referred to as morning stiffness. It is the inability to move the joints after a period of rest. The small joints of the hands and feet are commonly affected.

 Morning stiffness occurs because the joint stays imobile throughout the night while you are slleeping. People who stay awake and active during night, like watchmen, may complain of evening stiffness instaed of morning stiffness.

• People with a family history of arthritic condition.

These symptoms are not highly specific for rheumatoid arthritis. The same kinds of symptoms also appear in following diseases, too.
 

• Postviral Arthritis
• Seronegative spondyloarthropathies
• Polymyalgia Rheumatica
• Acute Nodal Osteoarthritis

Therefore specific investigations are required to confirm th diagnosis. So, if you are suspected to have rheumatoid arthritis, your doctor will initially do the following tests.

• ESR
• CRP

Rheumatoid arthritis is a inflammatory disease of the joints. Therefore, the inflamatory markers of the body such as ESR and CRP should be elevated.

But these two tests alone are not diagnostic for rheumatoid arthritis. So if they are elevated the doctor will order a test for rheumatoid factor. This is positive in 80% of the patients with rheumatoid arthritis. A negative result does not entirely rule out rheumatoid arthritis, because they might be having sero negative rheumatoid arthritis.


Treatment available for rheumatoid arthritis

Early visit to rheumatologist is essential for the better management of the disease. Even though rheumatoid arthritis is a very concerning illness, the patient should understand that it can be managed and the patient can live a almost normal life if he/she follows the treatment schedule tightly.

25% of the patients have a chance of recovering entirely, which gives every rheumatoid arthritic patient a hope.

The management involves drug therapy and physiotherapy.

Does Acupuncture helps to relieve rheumatoid arthritis?

There are evidence that patients with rheumatoid arthritis seemed to be relieved by other intervention methods like acupuncture, and ayuruvedic methods . If you are interested, you should check on that too, but don't forget your routine medications and physiotherapy.
 

References:

Kumar and Clark's clinical Medicine Seventh Edition

Hutchison's Clinical Methods 22nd Edition

Bailey and Love's Short Practice of Surgery 25th Edition

Hip Joint Replacement

Replace your hip, and you'll be able walk just like before. This is one of the miracles achieved by the advancement of the medical and surgical practices.

Hip replacement (joint replacement) surgeries are done in increasing numbers throughout the world. This indicates the high positive outcome rates of the surgery. A total of 50 000 total hip replacements are been done in United Kingdom every year.

The prognosis of the surgery is very good and 95% of the patients are found to have a almost normal joint movements without any pain. The replaced joined may function really well even for more than 20 years. 

As a result of high number of people getting their joints replaced, the number of people with failure is also increasing, but this is a relative increase, not an absolute one.

I have met with several patients who had to get their hip joints replaced due to advanced stages of rheumatoid arthritis  and osteoarthritis. One of them had a her both knee and hip joints replaced and now her condition has really improved. She says that now she can walk with no pain at all.

References:

Bailey and Love's Short Practice of Surgery 25th Edition

Russell’s Silver Syndrome

One day I saw my colleagues gathered in the play room of the pediatric ward. I heard someone talking, but the voice didn’t sound like a child’s voice, neither a grown up’s. It was like an ant talking loud and clear. The sound reminded me of the aliens that were in a cartoon that I watched when I was little.

I peeked through the crowd and was surprised by what I saw. The sound came from a little child who was really small in size. He was a little taller than a new born baby, but he could stand, talk, eat and   everything else that a 5 year old could do. The most interesting thing was that his intelligence was better than a five year old. He was very witty and playful. He talked to everybody around him. Everybody seemed to be fascinated by his presence.

There was something unusual in his face. His face was triangular which reminded me of the Russell’s Silver baby in the text book. Yes, this child was also a one with the Russell’s Silver syndrome.

I talked to the mother and found out that her marriage was a consanguine marriage, but I looked in the book and in the internet and found out that consanguinity does not cause this syndrome.

His mother, unlike many mothers with syndromic babies was very happy and was not angry with anybody. She was very cooperative and seemed to be happy about the way her child was talking to everybody in the ward. It was a quality that I always admired in her and always will.

I've seen mothers who didn't even like to talk with anybody. They were very uncooperative when we went to see their children. But this mother was different. She said that her child is a gifted child. He is very lovable. She said that she will take care of him as long as she can and provide him with the best she could.