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Vol. 2 Issue No. 18
The Second Physician Attribute: Medical and Clinical Knowledge Medicine changes rapidly. Clinical practice and standards advance fast. We in the Hospital place great importance to the management of change. We al think that proper management of change is the one thing we must do al the time. For a physician to stay up-to-date he must adopt a pattern of life which enhances his knowledge and improves his skil s. A physician who spends much of his spare hours watching television cannot be up-to-date, and this wil eventual y show. Being knowledgeable in Medicine and being a competent medical practitioner cal s for extra effort on the part of the physician to hone his skil s and to enhance his knowledge. Proctoring for this attribute is looking for the practitioner to demonstrate not only knowledge, but know-how of established, up-to-date protocols, policies, procedures, and the best of evidence- based clinical practices. The attributes of the new physician must include his knowledge and use of evidence- based practices and guidelines. These guidelines emulate and fol ow the protocols from the best international y recognized medical centers of excel ence. The physician we want to work with must be versed in and familiar with the guidelines of these best practices which are reached by evolving biomedical, clinical, therapeutics and social sciences. Our physician must be able to demonstrate his confidence in his knowledge. The proctor is looking for the ability of the newly-appointed physician to apply his skil and his knowledge to patient care and the education of others. The proctored Practitioner must be able to demonstrate service quality. He is committed to quality; another pil ar on which the Hospital stands. The three pil ar of our practice in the International Hospital of Bahrain are SPS (Superior Patient Service), CQI (Continuous Quality Improvement) and constant innovation: with the ability to meet the changing needs of patients, col eagues and the Hospital. These three pil ars of quality and quests for enhancing quality of the Hospital Medical Staff are not theoretical, but part of our culture. The proctored physician must be seen to participate in superior patient service. He must be wil ing to adapt to innovation and improvement. He must be seen to contribute to and be part of the path to excel ence and improvement. He must show that he can adapt and make it his way or his new way of life. Continuous quality improvement has a momentum in the Hospital, and we evaluate the reaction and interaction of the new physician to this. We are looking at his enthusiasm and absorption in the quest of improvement of everything we do.
In the second attribute we are looking for a knowledgeable, scientific clinician whose practice is evidence- Vol 2 Issue No. 18May 2012 Editor-in-Chief: Dr. Faysal S. Zeerah Editors:• Dr. Dilip Malhotra • Dr. Nader Albert Ghobrial• Dr. Mona Issa Farrag• Dr. Meena Khalatkar • Dr. Ivo Fernandez Designer: Mildred Belen Published by: International Hospital of Bahrain, W.L.L.
PO Box 1084, Manama Kingdom of Bahrain.
Switchboard: +973 1759 8222Email: [email protected] 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.
FOCUS is published as a service to the community. Although every effort has been made to ensure the accuracy 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 reader's particular circumstances.

Obesity in Children Childhood obesity is a serious medical condition that affects children and adolescents. It occurs when a child is well above the normal weight for his or her age and height. Not al children carrying extra kilos are overweight or obese. Some children have larger than average body frames and carry different amounts of body fat at the various stages of development. Your child's doctor can help you figure out if the child's weight could pose health problems by calculating the child's body mass index (BMI). The BMI indicates if the child is overweight for his or her age and height. Using a growth chart, your doctor determines your child's percentile, meaning how your child compares with other children of the same sex and age. For example, you might be told that your child is in the 80th percentile. This means that compared with other children of the same sex and age, 80 percent have a lower BMI. • BMI-for-age between 85th and 94th percentiles — overweight • BMI-for-age 95th percentile or above — obesity Childhood obesity can have the fol owing complications: • Type 2 diabetes. Type 2 diabetes in children is a chronic condition that affects the way your child's body metabolizes glucose (sugar). Type 2 diabetes is caused in part by poor diet and can often be reversed by eating healthier foods and • Metabolic syndrome. Metabolic syndrome isn't a disease itself, but a cluster of conditions like high blood pressure, high blood sugar, high cholesterol and excess abdominal fat that can put the child at risk of developing heart disease, diabetes or other health problems.These factors can contribute to the buildup of plaques in the arteries. These plaques can cause arteries to narrow and harden, which can lead to a heart attack or stroke later in life.
• Asthma and other breathing problems. The extra weight on the child's body can cause problems with the development and health of your child's lungs, leading to asthma or other breathing • Sleep disorders. Sleep apnea, a condition in which the child may snore or have abnormal breathing when he or she sleeps, can be a complication of childhood obesity. • Early puberty or menstruation. Being obese can create hormone imbalances for your child. These imbalances can cause puberty to start earlier than expected.
• Low self-esteem and bullying. Children often tease or bul y their overweight peers, who suffer a loss of self-esteem and an increased risk of depression as a result.
• Behavior and learning problems. Overweight children tend to have more anxiety and poorer social skil s than normal-weight Dr. Mona Issa Farrag

Implantable Contact Lenses
Don't want Glasses? Don't want LASIK? Don't want to wear contact lenses? We still have a solution - IMPLANTABLE CONTACT LENSES What are Implantable Contact Lenses (ICL)? Implantable collamer lenses (ICL) are a type of After this treatment, the patient can leave the phakic intraocular lenses which are specialized hospital after a couple of hours and is able to enjoy lenses made of plastic or silicone material which new sight almost immediately and go back to his/ are implanted into the eye to permanently reduce a her active lifestyle.
person's dependence on glasses or contact lenses. They are called Phakic lenses as they are implanted The ICL is invisible to the naked eye: The ICL works into the eye without removing the eye's natural like a contact lens. The difference is that the lens is lens. The lens is inserted through a small incision placed inside your eye, rather than on the surface. and placed just in front of or just behind the iris.
The only way that you will know that it is there, is the improvement in your eyesight. You can not see The lens is soft and tiny, much like the natural lens, the lens once it is inside your eye.
but does not replace it. The ICL is specially shaped to correct nearsightedness or farsightedness. Deciding to Go Ahead? Phakic lenses once placed in the eye, focuses the Talk to your doctor about your expectations, medical light rays on the retina providing clear distance history, eye history, or past eye examination. This vision without the aid of glasses or contact lenses. will help you decide whether phakic lenses are right Advanced phakic lenses, also called as Toric ICL go for you. After a detailed eye examination, you will a step further. They can also correct the cylindrical be counseled and provided the various options of vision correction.
What makes ICL Special? Talk to your doctor about your expectations, ICL treatment is completely safe even if you have medical history, eye history, or past eye thin corneas, surgically stabilized keratoconus, examination to help you decide whether phakic dry eyes, or large pupils as it does not involve lenses are right for you removing tissue from the cornea. It is also suitable for candidates who are otherwise unfit for laser vision correction and can correct a large range of refractive errors. In addition ICL gives the patients the ability to see well in low light such as dusk or at Dr. Deepak KhoslaOphthalmologist Throat Irritation Patients present with several throat symptoms like irritation, tickle, cough, throat clearing and a sensation of mucous in the throat.
irritation because of the substances contained in In the majority of cases, there is little to find on the smoke, it causes further drying and promotes examination of the ear, nose and throat. However, mouth breathing.
a thorough examination is mandatory to exclude more serious il nesses. Most patients can be easily  Anxiety and Stress. Stress causes an overall managed with reassurance and careful explanation increase in muscle tension and this effect is often that the throat is a very sensitive area and the cough noticed in the throat, either as a mild change in reflex is a natural protective mechanism to an irritant.
the quality of voice, or as a sensation of tightness or lump in the throat which then leads to constant Common Causes of Throat Irritation throat clearing. Stress also increases acid production in the stomach, which may worsen the  Reflux. Acid stomach contents may pass upwards effect of reflux. to the throat causing irritation as a result of low-level chemical burn. In fact GERD (gastro-  Coughing and Throat Clearing. The very act esophageal reflux disease) is a common cause of of coughing or throat clearing can actual y cause chronic sore throat, cough and inflammation of throat problems to become worse or longer lasting. the larynx (wind pipe).
This occurs as a result of the violent bringing together of the vocal cords, which in itself can  Mouth Breathing. The nose is the air conditioner cause inflammation of the throat. This can quickly for the respiratory tract. It warms and moistens lead to a self-perpetuating condition.
the air we breathe. If the nose gets blocked and mouth breathing takes over, then this effect is lost  Infection. Upper respiratory tract infections can and the throat and the air ways become dry and sometimes lead to long lasting throat problems. This occurs as a result of excessive coughing and swal owing of mucous, in addition to inflammation  Rhinitis. Rhinitis causes nasal block with nasal of the throat. These effects can continue long after and post nasal secretions. The latter drips to the the cold itself has gone. back of the throat causing irritation and excessive  Drugs. Some drugs can cause cough or throat irritation. ACE inhibitors (drugs used for lowering  Asthma. Many patients with rhinitis also have the blood pressure) often cause dry cough. Non asthma, and vice versa. People with al ergic steroidal anti inflammatory drugs can increase rhinitis and asthmatic bronchitis can have acidity and reflux.
sensitivity in the area in between, i.e. the throat.
 Poor air quality. Pol utants, fumes, dust and smoke cause irritation of the lining of the throat. Also air conditioning and central heating dries up Dr. Hisham Halabi the air leading to a dry, poor quality air. This can have adverse effect on the throat.
 Smoking. Smoking has serious effects on the lining of the throat. In addition to causing Intra-Articular and Soft Tissue Injections Intra-articular and soft tissue injections of steroids • Infection: Local or systemic are useful in control ing refractory pain, suppressing • Intra-articular injury/Haemarthrosis inflammation, and increasing joint function in patients • Severe joint destruction with instability with arthritis and musculoskeletal disorders. • Regional osteoporosis • Anticoagulant patient • Uncontrol ed diabetes The clinical effects of local steroid injection are anti- • Unclear diagnosis inflammatory with a diminution of redness, swel ing, heat and pain. There may be a systemic improvement Frequency of Injection in function as wel . The clinical efficacy is wel known Conventional opinion holds that three injections can but the biochemical mechanism is unclear. be given safely into the same joint over a 12-month period. In addition, response to previous injection Different theories have been proposed, including is a relevant factor in deciding whether and when stabilisation of lysosomal membranes, inhibition to proceed with re-injection. Significant therapeutic of cel ular metabolism and decrease in synovial benefits fol owing injection support the use of a second injection when the symptoms have returned. Failure to obtain significant relief after two injections clearly argues against additional injections.
• Rheumatoid Arthritis • Seronegative arthropathies: Ankylosing Spondylitis, Dosage and Volume Psoriatic Arthritis, Reiter's Syndrome Tendons and ligaments should have minimum possible • Crystal induced Arthritis: Gout & Pseudo gout amount of volume and steroid injected. A smal volume • Osteoarthritis with Synovitis avoids painful distension of the structure and the • Bursitis: Subacromial, Olecranon, Pes anserine, smal dose minimises risk of rupture. Most tendon Pre-patel ar, Trochanteric lesions and smal joints need 10-20mg of steroid and • Tendinitis/Fasci tis: Supraspinatus, Bicipital, de 1-2 ml of local anaesthetic. Larger joints and bursa Quervain's, Tenovaginitis/Trigger finger, Plantar require 30-40mg and 5-10ml of local anaesthetic.
fasci tis/heel spur • Entrapment Neuropathies: Carpal Tunnel Problems with Injection Therapy Syndrome, Tarsal Tunnel Syndrome Problems arise when: • An inappropriate drug is chosen. Virtual y insoluble steroid suspensions are used because intra- articular soluble steroids wil rapidly clear into the Dr. Dilip Malhotra systemic circulation. Methyl Prednisolone acetate Orthopaedic Surgeon (Depo-Medrol) and Triamcinalone acetonide (Kenacort) are best suited for the purpose. Hydrocortisone is short acting.
• Too large a dose is used.
Intra-Articular and Soft Tissue Injections of Steroid • Injections are given too frequently.
• Spread of drug to adjacent tissues.
• Insufficient attention is directed to the cause of the lesion.
• Improper aftercare.
• Systemic: Facial flushing, menstrual irregularities, impaired diabetic control, syncope (fainting), anaphylaxis (usual y to the local anaesthetic). • Local: post injection flare of pain (due to crystal induced synovitis), skin depigmentation, subcutaneous atrophy, bleeding/bruising, soft tissue calcification/steroid chalk, tendon rupture, steroid arthropathy, joint/soft tissue infection (rare). Advice to Patients • Immediate pain relief due to the effect of the local anaesthetic wil disappear in a couple of hours.
Headache is a common complaint which we all experience every now and then. It is a major symptom in many of ordinary illnesses such as common cold, errors of • Occasional y initial worsening of refraction, sinusitis, tooth problems, constipation, etc.
pain may occur (treat with rest, ice, Paracetamol or anti inflammatory To consider headache as an alarm for a serious illness, it must be of a specific character and is usually accompanied by other symptoms • The steroid may take several days to of clinical importance: become effective. • Physical exertion of the part should be 1. Unilateral headache: Unilaterality is very significant and should avoided for two weeks.
always arouse suspicion of an underlying pathology such as brain tumor or vascular lesion.
Intra-articular and soft 2. Chronicity: Chronic headache should call for more investigations as MRI or CT scan of the brain as well as EEG to rule out any tissue injections of steroids are useful in controlling 3. Change in the character of the headache: "I have never refractory pain, suppressing experienced like this before ". This is a common statement which inflammation, and should always be taken seriously.
4. History of trauma or fever.
increasing joint function in 5. Other important associated symptoms: patients with arthritis and • Blurring of vision or double vision musculoskeletal disorders. " • Projectile vomiting • Weakness in one or two limbs on one side (usually opposite • Deterioration in conscious level or difficulty in speech • Difficulty in walking or maintaining balance • Urinary or stool incontinence Dr. Hassan MouktharNeurosurgeon SCREENING MAMMOGRAPHY: What Everybody Should Know Other types of breast screening Dr. Sagiraju Varma Digital mammography is similar to film screen mammography but images are acquired in digital form. Sensitivity and specificity of screening ultrasound are not Screening mammogram is a radiographic Present indications are for evaluation of breast nodule examination of the breasts performed for early (solid or cystic), clinically occult mammography findings detection of breast cancer in asymptomatic in dense breast tissue, supplementary examination of women with high risk breast cancer and guidance during It is recommended that women get mammogram done at age of forty and annually thereafter.
Screening MRI is not used in every day clinical practice. Present indications are pre-operative local staging, There are instances when screening should start earlier. differentiation between post operative scar and Patients with history of Hodgkin's disease treated recurrence carcinoma, CUP [Carcinoma with Unknown with radiation or those with strong family history of Primary] syndrome, prosthesis and problem cases.
breast cancer. A woman treated for Hodgkin's disease surveillance may begin 10 years after chest wall/ Role of primary physicians mediastinal irradiation. For patients with history of first The most important thing is to recommend a degree relative, screening should begin 10 years before mammogram for asymptomatic women. Reassure that the age at which the relative was diagnosed.
mammography should not be painful, although certain degree of temporary compression is necessary to obtain For routine mammography, four views are obtained. Additional views may be required in some patients. The amount of radiation for routine mammogram is very small Remind the patient to bring all the previous [0.2 rads/2mGray]. mammograms to the imaging center at the time of next examination. Also remind that she may be called back The risk for developing cancer due to bilateral for additional views. The call back does not always mean mammography in a 45 year old is 0.0055%.
something is wrong.
Benefits of mammography are seen immediately; the potential side effects after 20-30 years.
Comparison filmsIf the patient has multiple sets of prior films, radiologists KEY POINTS like to compare with the studies that are two years old.
• Annual screening mammography should begin Sensitivity of screening mammography depends on the • Mammography is stil the best screening test to density patterns; the sensitivity seems to decrease as detect sub clinical breast cancer.
the glandularity of the breast tissue increase.
• The sensitivity of mammography is in the range Difference between screening mammogram and diagnostic mammogram • False negative rate is approximately 10-15%.
A screening mammogram is performed on asymptomatic • An individual's risk of developing breast cancer patients as part of routine annual surveillance. A increases with increasing age.
diagnostic mammogram is performed when the patient • Most breast cancers occur in women with no has history of breast cancer or presents with breast family history of the disease.
related complaint.
Day-Care Anaesthesia Day-care surgery offers several advantages to patients, doctors, and insurance companies. Recent advances in medical technology, anaesthesia and pain management have allowed a huge expansion of this modality of care with a consequent reduction in the need for hospitalization. Successful conduct of procedure is based on : • careful patient selection.
• type of surgeries based on the facilities available.
• Postoperative nausea and vomiting. The incidence • appropriate preparation and planning.
varies between 2.2% and 4.6% and this may delay the patients discharge at times.
There is no significant relationship between pre- existing diseases, extremes of age and incidence of Postoperative pain is the most significant complaint perioperative complications in a day care setting, following ambulatory anaesthesia. Factors associated provided proper attention is paid to preoperative with severe pain in the post anaesthesia care unit assesment, prepration and discharge planning. (PACU) include younger adults, patients with a Children are excellent candidates for daycare surgery larger body mass index (BMI), prolonged duration of as it provides minimal separation from parents and surgery, orthopaedic, urological and plastic surgeries. minimal exposure to potentially contaminated hospital A concept of multimodal analgesic technique with combination local anaesthetics, non-steroidal anti- inflammatory drugs (NSAIDs), opioids has shown Pre Procedure Evaluation and Preparation better results.
In addition to reducing anxiety about the surgery and anaesthesia, it identifies potential medical problems in • Post dural puncture headache. Due to early advance and initiates appropriate corrective measures. ambulation in patients having spinal anaestheisa it Thereby, minimising the numbers of cancellations and is almost negligible with use of small 25- or 27-gauge The patients are allowed clear liquids up to 4 hours Recovery and Discharge Process before surgery, without increasing residual gastric The Aldrete Score is used for evaluating patient recovery volume. Administration of antacid and antiemetic can after anaesthesia and patients' "home readiness" is reduce both residual gastric volume and acidity. The assessed with modified Post Anaesthesia Discharge patients should take all chronic oral medications up to 1 Scoring system (PADSS). These scores are useful in hour before the procedure.
allowing documentation of objective measurements of clinical recovery. Total intravenous anaesthesia (TIVA) provides Following day care procedure, patients should be advantages for all short surgical procedures, as even discharged home with an adult escort, who ideally will after prolonged infusion there is rapid recovery .
continue overnight supervision of patients' recovery and patients should also have ready access to healthcare Spinal anaesthesia, commonly used with local anaesthetic agents specific to the expected duration of surgery, provides superior recovery profiles . Newer technology i.e. ultrasound-guided interscalene Dr. Avijit Gaikwad and supraclavicular blocks are used effectively and safely for shoulder and hand surgeries as compared to landmark based nerve blocks. After Tooth Extraction Extracted tooth socket heals over a period of one to two weeks, gum tissue takes about 3-4 weeks and complete healing of the bone can take about 6-8 months depending on your care of this area. Some discomfort, bleeding and swelling is be expected in the first 24 hours. Following these simple instructions will normally be Medications: Pain medications may be taken every all that is needed.
four hours as needed. Do Not Disturb the Wound: Simple pressure from Swelling: To prevent swelling, apply an ice pack a piece of gauze is usually all that is needed to outside of your face in the area of the extraction control the bleeding and to help a blood clot to during the first 24 hours. This is the best way to form in the socket. Blowing your nose or sneezing avoid excessive swelling. violently can dislodge the blood clot and impair Diet: For the first 24-48 hours, you should maintain a soft diet. Also avoid carbonated drinks and Do Not Smoke or Use Tobacco Products or Alcohol hot beverages for 3-4 days. Eating immediately for 72 Hours because smoke can interfere with the following the procedure is not recommended. healing process, promote bleeding and can cause a very painful situation known as "dry socket". For Women Only: If you are taking birth control pills or are in the first 22 days of your menstrual Brushing: It is important to keep the area as cycle, your are twice as likely to develop a ‘dry clean as possible to prevent infection and promote socket', which is a very painful condition, after an healing. This area can be gently and carefully wiped with a clean, wet gauze pad or cloth. After 48 hours teeth may be brushed and flossed gently. Anesthesia Warning: When a local anesthetic is used your lip, tongue and cheek will be numb for Mouthwash: Avoid all rinsing for 24 hours after several hours after the procedure. During this extraction. After the first 24 hours you should period you must be careful not to bite or scratch gently rinse of this area using warm salt water or this area which can lead to serious soft tissue mild antiseptic.
Bleeding: Follow the verbal instructions regarding Follow-Up Appointment: You are required to return the control of postoperative bleeding. It is normal for follow up in one week to check on the healing of for some blood to ooze from the area of surgery for this area.
12 hours. We will also give you a packet of gauze to take with you to use at home if the bleeding continues. Hold it firmly in place, by biting down on the gauze pad for about 30-60 minutes.
Dr. John MeakkaraDentist the Big Little ThyroidThe thyroid is a small gland situated in the front of the neck below the Adam's apple and can usually neither be felt nor seen. However this little gland is a very big player when it comes to survival. The thyroid gland affects every cell in the body by increasing metabolism, within the cells, when When the metabolic rate of a cel is increased, the cel requires a larger amount of fuel which is basical y oxygen and substrates in the form of carbohydrate, weight despite over eating.
fat or protein. And when anything burns, there is 4. Musculoskeletal system. There is a loss of heat produced as a by-product. To increase delivery weight and a decrease in muscle mass.
of oxygen and food to cel , the cel has to receive a 5. Urogenital system and sexual greater amount of blood supply and therefore the characteristics. Thyroid hormones in physiologic heart has to work faster and harder. The thyroid amounts are necessary for every aspect of sexual hormones also potentiate the action of circulating development and function.
catecholamines (substances of "fight and flight") and, therefore, the action of normal circulating levels of One can see that a decrease in circulating thyroid catecholamines is amplified. By affecting the cel the hormone leads to an exact opposite of the above thyroid affects various organ systems in the fol owing When we talk about common thyroid afflictions, we 1. Brain. In the foetus and growing child, thyroid talk about an overactive thyroid, an under active hormones are required for brain development thyroid, a thyroid that is enlarged and presses on and lack of it early in life causes the brain to adjacent structures causing problems with breathing, remain under developed. Increased activity in swal owing and voice change, and final y a thyroid the Reticular Activating System (center that is that is cancerous.
responsible for keeping us awake) and other parts of the brain make us anxious, alert and Common investigations include the thyroid function awake, causes muscles to contract briskly and tests of which the TSH or thyroid stimulating hormone stay contracted for longer than is usual. These are is the most important, ultrasound scan of the thyroid, seen as an inability to sleep, tremors, a staring fine needle aspiration cytology of the thyroid, thyroid look, being hyperactive.
antibodies and isotope scan.
2. Heart. Increase force and rate of contraction thereby increasing the amount of blood flowing Treatment may be with drugs, surgery or with radio out of the heart and this manifests as a pounding active iodine ablation depending on what the problem rapid pulse.
is or may include a combination of the above.
3. Intestines. Because the thyroid hormones increase requirement of food, the person develops an increased appetite and eats more. Because there is increased activity of muscle cel s of the Dr. Ivo Fernandez intestines, the intestine contracts faster causing diarrhoea. However even this increased food intake is not sufficient and often cel s borrow from body stores and there is paradoxical y a loss of ULTRASOUND IN PREGNANCY:
Of course, initialy, skeptics, mostly from the medical community, were indignant at this "violation" of the secrecy of the pregnancy. Ultrasound was accused of al possible evil side effects. However, with time and technical advances, and despite the ferocious war of the "skeptics", ultrasound became the eyes and the ears of modern obstetricians, al owing them to make valid decisions for best fetal outcome. Most importantly, in more than 50 years of ultrasound use, and contrary to what the skeptics were claiming, not a single fetal or maternal untoward effect has been reported from the use of ultrasound. Perhaps the only drawback is the financial aspect, as an obstetrical ultrasound may be However, over the years, it has been suggested that low risk pregnant women may not benefit from any ultrasound done during their pregnancy. On the other hand, some obstetricians have suggested (and are actual y practising) ultrasound on every pregnant woman coming for every antenatal visit. There is no doubt that high risk pregnancies should al be checked with frequent ultrasound. Obstetricians wil be amazed at the amount of information they Though skeptics were can obtain from even a quick ultrasound (amniotic fluid, presentation, placenta, etc.), information that indignant at the "violation" of could have been unsuspected before, and when the secrecy of the pregnancy, found, could make a tremendous difference to the ultrasound became the eyes and the ears of modern But frequent ultrasound exam though safe, should obstetricians, allowing them to not be imposed on low-risk pregnant women, unless they ask for an ultrasound. In fact, majority of patients make valid decisions for best show tremendous satisfaction when they are given the fetal outcome.
chance to watch their fetus by ultrasound, especial y the 4D ultrasound. As obstetrical ultrasound has been shown to be safe so there is no reason to deny this satisfaction to pregnant women.
Antenatal care has been so much emphasized not only for its medical necessity, but also for its psychological Dr. Roland MouawadOb-Gynaecologist and emotional support to pregnant women. Obstetrical ultrasound is a major factor enhancing this kind of support. It may not be medical y indicated, it is certainly psychological y and emotional y very much Urinary Tract Stones The first documented urinary tract stones were found among the 7,000 year-old remains of the pelvis bones of teenage boy in El-Amara. Before the industrial revolution in Britain, stones in the bladder were more common than in upper urinary tract. Around the turn of the nineteenth century, upper tract stones disease began to become more prevalent. In developing countries, bladder stones are still endemic and is more common in males.
The presenting symptoms of upper urinary tract stones are loin pain which may radiate to the groin in a colicky nature sometimes associated with hematuria (blood in urine). If urinary infection is present there may also be symptoms and signs of infection as dysuria (pain while • Sedentary occupations passing urine) and frequency of micturition. Bladder • Anatomical abnormalities of the urinary tract calculi (stones) may cause changes in the urinary stream due to the stone acting as a bal valve over The common types of the stones are: the bladder neck and the symptom of strangury (slow • Calcium oxalate, calcium phosphate or combinations painful urination) due to strong painful contraction of the • Uric acid, cystine.
bladder in attempt to evacuate a calculi.
• Magnesium ammonium phosphate (Struvite).
Risk factors for stone formation • Presence of promoters of stone formation High risk patients with urinary symptoms especial y loin • Absence of inhibitors of stone formation pain and hematuria need to be evaluated by: • Urinary tract infection • Urine analysis and culture.
• Urinary stasis • Blood tests for renal function, calcium, uric acid, • Concentrated urine due to poor fluid intake phosphate and magnesium.
• Diet too high or too low in calicum • Plain X-ray kidney, ureter and bladder (KUB) • Ultrasound kidney, ureter and bladder • Intravenous pyelogram ( I.V.P ) A kidney stone is a hard mass developed from • C.T scan crystals that separate from the urine within the urinary tract.
Treatment is according to the size and the position of stone by medical or surgical means; endoscopic or open surgery especial y for the stag- horn stone. Some stones can be crushed by special instruments or by extra corporal shock wave lithotripsy (ESWL) .
Fainting is defined as a loss of awareness or consciousness for an interval of time. The medical term used to describe fainting is syncope.
How does it occur? Fainting occurs when the blood supply to the brain is not enough for its functioning. This may happen in any condition when the heart is not able to pump enough blood to the brain as in case of heart valve problems; and if the heart rate is either too slow or too fast. It may also happen if the person is fasting for too long resulting in fall in his blood sugar level.
What are the symptoms of fainting? The symptoms that a patient may feel before fainting are palpitations, i.e. feeling or hearing the heart beating very fast, nausea, dizziness, weakness or a black out.
How is it diagnosed? The doctor should be consulted immediately to find out the cause. The doctor will take the patient's medical history, check the pulse and blood pressure. He will also suggest some lab tests and electrocardiogram (ECG). The ECG is a recording of heartbeat. He may also suggest echocardiogram which is an ultrasound scan of the heart to find out any abnormality in the heart valve. How is it treated? The treatment will depend upon the cause of fainting. In case of abnormality in heartbeats, medicine will be prescribed. In case of reduction of blood flow to the brain because of problems in the blood vessels, specific blood flow increasing drugs may be prescribed.
What first aid can be provided? The patient returns to consciousness when normal blood flow to the brain returns. The patient should be made to lie down with his legs in a raised position. If the patient has normal breathing, his legs should be raised above the level of his chest as this will help in supplying more blood to the brain and help the patient to come back to normal. To prevent fainting in future, avoid sudden changes in posture and intense Religion, Spirituality, and an experience includes support for the patient's suffering, the avoidance of undesired artificial Dr. Samy GoudaNeurosurgeon prolongation of life, involvement of family and/or close friends, resolution of remaining life conflicts, and attention to spiritual issues that surround the meaning of illness and death.
Clinicians can and should help dying patients find meaning and hope through recognition of the Spiritual, religious, and cultural beliefs and practices play a significant role in the lives of patients who are seriously ill and dying. In addition to providing an ethical spiritual dimension of their experience. Although foundation for clinical decision making, spiritual they may lack the expertise to address spiritual and religious traditions provide a conceptual concerns in depth, healthcare professionals should framework for understanding the human experience be able to discuss spirituality with their patients of death and dying, and the meaning of illness and and identify those in spiritual distress so that suffering.
appropriate referral may be made to spiritual care providers. These include chaplains, community- The importance of spiritual and religious beliefs based clergy, spiritual directors, pastoral in coping with illness, suffering, and dying is counselors, and culturally based healers. supported by clinical studies as well as individual narrative descriptions. Most patients derive Spiritual care is recognized as a necessary domain comfort from their religious/spiritual beliefs as they of palliative care. Guidelines for interprofessional face the end of life, and some find reassurance spiritual care as well as an implementation model through a belief in continued existence after for spiritual care were developed by a national physical death. However, religious concerns can consensus conference of experts. In their report, also be a source of pain and spiritual distress, for practical tools as well as recommendations are example, if a patient feels punished or abandoned presented to help clinicians integrate spirituality by God. Furthermore, beyond the role of religious more fully into patient care.
faith in coping and adjusting to illness, religion also influences patient's medical decisions, both about active treatment and end of life care.
A common goal for the dying patient, family members, and the health care professional is for a meaningful dying experience, in which loss is framed in the context of a life legacy. Such A common goal for the dying patient, family members, and the health care professional is for a meaningful dying experience, in which loss is framed in the context of a life legacy. Though pomelo juice is acidic in nature, it helps in the digestive process of the body, by having an alkaline reaction after digestion. • Pomelo rind contains huge amount of bioflavonoid that can stop the cancer cel s from spreading the effect of breast cancer in a patient, by making the body get rid of the excess estrogen.
Nutrition Facts • The high amount of vitamin C present in the body makes the fruit an effective stimulant that facilitates in strengthening and maintaining the elastic nature of the arteries. Amount Per Serving • Pomelo is also effective against fatigue, diabetes, fever, Calories 72 Calories from Fat 1 insomnia, sore throat, stomach and pancreatic cancer and other such infectious diseases.
% Daily Value*Total Fat 0 g • Pomelo contains pectin which proves to be very effective in Saturated Fat 0 g reducing the accumulation of arterial deposits in the body, thereby clearing out al the impurities.
Cholesterol 0 mg • Pomelo is also useful in reducing the cholesterol count in the Total Carbohydrates 18 g body, thus saving you from running the risk of various heart Dietary Fiber 2 g related problems. SugarsProtein 1 g • Pomelo can also prove out to be useful for people seeking out weight loss. The fat burning enzyme in pomelo absorbs Vitamin A 0% Vitamin C 193% and reduces the starch and sugar content in the body Calcium 1% Iron 1% contributing towards weight loss.
*Percent Daily Values are based on a • Pomelo is also useful in cleaning the RBCs which are very 2,000 calorie diet. Your daily values may be higher or lower depending on your essential for the body to breathe fresh air. It keeps the RBCs calorie needs.
away from al sorts of toxins and impurities.
Confront Your Exercise Enemies it
What gets in the way of your exercise? Whether it's work, the couch, your kids, or the grubby fella e
hogging the treadmill, now's the time find a way to work around these roadblocks to success. Today, you will overcome one of your exercise enemies. The truth is that there's a way around every exercise obstacle. It just takes a little planning and persistence.
Do you have trouble getting moving when you get home from work as you're drawn into reruns of The Office? Pack a bag in the morning and hit the gym, or go for a walk before you head home. Are you a stay-at-home mom and can't find anyone to watch the kids? Put them in a stroller or jog alongside as they ride bikes or scooters. The kids get some fresh air and exercise, too! source: Sharecare

Source: http://www.ihb.net/pdf/newsletter/2012/issue182012-lowres.pdf

Getting more out of blood gas

Evolution of Blood Gas Analysis - Focusing on the Source of Impaired O2 Supply to the Tissue Ellis Jacobs, Ph.D, DABCC, FACB Associate Professor of Pathology, NYU School of Medicine Director of Pathology, Coler-Goldwater Hospital and Nursing  Why measure blood gases  Overview of acid-base disturbances  Use of the Acid- Base Chart


Clinical Case Studies Cognitive Behavioral Treatment of Postpartum Onset: Obsessive Compulsive Disorder With Aggressive Obsessions Lisa M. Christian and Eric A. Storch Clinical Case Studies DOI: 10.1177/1534650108326974 The online version of this article can be found at: Additional services and information for can be found at: