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
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
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.
Vol 3 - Issue No. 34 - September 2013
Editorial Team
Honorary Editor:
Dr. Faysal S. Zeerah
Dr. Dilip Malhotra
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.
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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 reader’s particular circumstances.
3 1st Paediatric International Conference
4 ACHSI Accreditation Success
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
Monitoring Under
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 :
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 is monitored continuously by both direct and
indirect means.
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
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
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 “core” 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
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.
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Dr. Avijit S. Gaikwad
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.
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.
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.
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.
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
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).
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Dr. Magdy Kamal
General Surgeon
(Part 2 of 2)
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
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).
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.
Current treatment is aimed at easing the symptoms,
reducing inflammation, and controlling the immune
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
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
Interferon alfa-2a may also be an effective alternative
treatment, particularly for the genital and oral ulcers.
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Dr. Peter Farag
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
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
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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.
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 baby’s skin is allergic
Skin conditions or infections that happen in the diaper
area but are not caused by wearing a diaper.
Red, painful, or itchy skin
Raised, peeling, or scaly areas
If a baby’s diaper rash is caused by a skin condition or
infection, the rash can be on other body parts, too.
Diaper rash can be treated at home. Show the child to your
doctor if:
The rash gets worse or doesn’t get better after a few days
of treatment.
Your baby has diarrhea or a fever of 38°C or more.
Diaper rash is treated as follows:
Take the diaper off to air out the skin as much as
Check your baby’s diaper every 2 or 3 hours, and
change it when it is wet.
Change your baby’s diaper right after each bowel
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
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.
Change your baby’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
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Vaccination Myths and
Myth: Breast-fed babies don’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: It’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 aren’t really
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
Vaccines are good.
Vaccines save lives.
Vaccine benefits far outweigh the pain and minor adverse
Dr. Mohamed El Biltagi
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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.
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
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.
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
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Myofascial Pain Dysfunction
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.
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.
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 “spray and
stretch,” 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
Dr. John Meakkara
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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.
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.
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.
Both HCoV-HKU1 and HCoV-OC43 (Types of Corona
Viruses) have been found in infants hospitalized with
diarrhea (often with respiratory symptoms as well).
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.
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.
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Dr. Ehsan Sabry
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.
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.
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.
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.
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
Wearing shoes, long-sleeved shirts, and long pants when you go
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
Staying indoors at night
Dr. Hady Mohammed Gad
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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
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
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.
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Dr. Nader Ghobrial
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
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
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
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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
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:
Pain or discomfort in the scrotum
Feeling as though the scrotum is heavy or full
Swelling or irritation in the skin around the scrotum
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
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
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Health Related True Facts
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
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
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.
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