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 . 4 Is s u e N o . 4 2 W. L . L FOCUS Ma y 2 0 1 4 NEUROSURGERY DEPARTMENT FOCUS Vol 4 - Issue No. 42 - May 2014 Editorial Team Honorary Editor: Dr. Faysal S. Zeerah Editor-In-Chief: Dr. Dilip Malhotra Editors: Dr. Sanjeewani Gawhale Dr. Mona Issa Farrag Dr. Ivo Fernandez Dr. Ashraf Abbasy Graphics and Design: Bryan Boter Published by: International Hospital of Bahrain, W.L.L. PO Box 1084, Manama Kingdom of Bahrain. Switchboard: +973 1759 8222 Email: [email protected] Website: www.ihb.net For Appointments, please call +973 17598 200 How are we doing? We need your feedback for continuous improvement and want to hear from you. We welcome a letter or email detailing your patient care experience. Excellent, good, bad, indifferent, let us know how we are doing! We constantly strive to offer the best care and customer service and appreciate your feedback. Thank You. CONTENTS IHB NEWS 3 Events and Health Promotions HEALTH FEATURES 4 Allergies 5 Halitosis (Bad Breath) 6 Carotid Artery Disease Steel Crowns in Paediatric 7 Stainless Dentistry 8 9 10 11 12 13 14 Mumps in Children 15 16 Spinal Cord Injury Diabetic Retinopathy Dental Braces for Adults Acute Prostatitis The Way Children Walk Keloid Disease Modifying Anti-Rheumatic Drugs Fight Stress With Health Habits 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. Visit our social media page 02 International Hospital of Bahrain W.L.L. How Medicine Should Be Quality Care Dedicated to the Community Fixed Price Surgical Packages for Cosmetic Procedures Plastic, Cosmetic & Reconstructive Surgery Face and Neck Lifts Botox and Fillers Nose and Ear Reshaping Surgeries Breast Augmentation, Reduction and Lift Liposuction Tummy Tuck Implants Autologous Fat Injection Body Lifts General Plastic Reconstructive Surgeries Dr. Salil Bharadwaj Consultant Reconstructive, Plastic & Hand Surgeon For details: www.ihb.net email: [email protected] Telephone - 1759 8287 Accredited by ACHS International until August 2017 | A BUPA International ‘QUALITY ASSURED’ Hospital International Hospital of Bahrain W. L.L. P.O. Box 1084, Manama, Kingdom of Bahrain VISIT OUR SOCIAL MEDIA PAGE: For appointments, please call +973 17598222 Email: [email protected] Web: www.ihb.net ihb.net theihb theihb in/theihb @ihbahrain Allergies Dr. Farooq Ahmed Hospitalist Allergies occur when the immune system reacts to a foreign substance such as pollen, bee venom or pet dander. The immune system produces substances known as antibodies. Some of these antibodies protect you from unwanted invaders that could make you sick or cause an infection. When you come into contact with the allergen, your immune system's reaction can inflame your skin, sinuses, airways or digestive system. The severity of allergies varies from person to person and can range from minor irritation to anaphylaxis — a potentially life-threatening emergency. While most allergies can't be cured, a number of treatments can help relieve your allergy symptoms. Types of Allergies Hay Fever- also called allergic rhinitis, may cause congestion , itchy runny nose , watery or swollen eyes. Atopic Dermatitis- an allergic skin condition also called eczema, may cause: itchy skin, red skin, flaking or peeling skin. Food Allergy may cause tingling mouth, swelling of the lips, tongue, face or throat, hives or anaphylaxis. Insect Sting Allergy may cause a large area of swelling at the sting site, itching or hives all over your body, cough, chest tightness, wheezing, shortness of breath or anaphylaxis. Drug Allergy may cause hives , itchy skin, rash, facial swelling, wheezing or anaphylaxis. Anaphylaxis. Some types of allergies, including allergies to foods and insect stings, have the potential to trigger a severe reaction known as anaphylaxis; a life-threatening medical emergency. Signs and symptoms of anaphylaxis include: 1. Loss of consciousness 2. Light headedness 3. Severe shortness of breath 4. A rapid, weak pulse 5. Skin rash 6. Nausea and vomiting 7. Swelling of airways, which can obstruct breathing Visit our social media page Common Allergy Triggers Airborne Allergens such as pollen, animal dander, dust mites and mold. Certain Foods particularly peanuts, tree nuts, wheat, soy, fish, shellfish, eggs and milk. Insect Stings such as bee stings or wasp stings. Medications particularly penicillin or penicillin-based antibiotics. Latex or other substances you touch can cause allergic skin reactions. You may be at increased risk of developing an allergy if you: Have a family history of asthma or allergies. You're at increased risk of allergies if you have family members with asthma or allergies such as hay fever, hives or eczema. Are a child. Although you can become allergic to something at any age, children are more likely to develop an allergy than are adults. Allergic conditions often get better as children get older. However, it's not uncommon for allergies to go away and then come back sometime in the future. Have asthma or an allergic condition. Having asthma increases your risk of developing an allergy. Also, having one type of allergic condition makes you more likely to be allergic to something else. 04 Halitosis (Bad Breath) Halitosis (bad breath) is a symptom where a noticeably unpleasant odour is present on exhaled breath. It is a health-associated problem that incurs a great amount of suffering and affects personal relations. The prevalence of bad breath ranges from 15 to 30 percent. Ironically, many people who worry about bad breath do not suffer from it, a condition known as halitophobia. Bad breath can be observed in all ages. CAUSES Oral Cavity — 80 to 90 percent of cases. Bad breath comes from bacterial accumulation between the teeth and the posterior part of the tongue. Dental abscesses, and unclean dentures may also cause foul odour. These bacteria breakdown amino acids present in stagnant saliva, food debris, and postnasal drip. Volatile hydrogen sulfide, and probably other gases that are by-products of amino acid degradation contribute to bad breath. Oral and Dental Pathology such as gingival inflammation and periodontitis, with poor dental hygiene may contribute to bad breath. Nasal Passages — Five to eight % of bad breath cases. It may be indicative of a nasal infection (such as sinusitis), or a problem affecting airflow or mucous secretions (eg, polyps). Young children inserting foreign bodies into their nostrils is a common cause of offensive nasal odor. Tonsils — Three percent of cases. Tonsilloliths are stones that form in crypts of the tonsils. It contains bacteria, which produce volatile sulfides, and some patients may complain of small stones on their tongue or tonsils that have a foul odour. Dr. Mohamed Maguid ENT Specialist An oral origin is suspected if the odour is confined to the mouth, while nasal involvement is suspected if the odour is confined to the nose. A systemic origin is suspected in which the odor emanates both from the mouth and nose. TREATMENT Patients with an identifiable cause of bad breath (eg, periodontal disease, gingivitis, postnasal drip, systemic illness) can be treated for these conditions. Antibiotics only results in transient relief, unless associated with other measures of treatment and prevention of bad odor. PREVENTION • Proper dental care and oral hygiene, including daily flossing. • Gentle cleaning of the posterior portion of the tongue dorsum with a plastic tongue cleaner or toothbrush. • Rinsing and deep gargling, most effective when done at bedtime. • Patients should use mouth rinse an hour or more following use of toothpaste. • Eating fibrous foods. • Chewing gum briefly if the mouth is dry, or after meals, especially with high protein intake. Sugar-free gum is preferable. • Sufficient water intake. • Decreasing alcohol and coffee intake. Others— Patients with heartburn, regurgitation, sour taste, and belching often complain of halitosis. Some diseases may rarely cause bad breath, including bronchial and lung infections, kidney failure, liver failure, cancers and metabolic dysfunction. DIAGNOSIS Although 'Electronic Nose' and other analyzers of volatile substances can analyze bad breath, no instrument is currently able to replace the human nose for diagnosis of bad breath. Visit our social media page 05 Carotid Artery Disease Carotid artery disease means atherosclerosis of the carotid arteries with fatty deposits (plaque) in the arterial wall. Progression of atheromatous plaque at the carotid bifurcation results in luminal narrowing, often accompanied by ulceration. This process can lead to ischemic stroke or transient ischemic attack (TIA) from embolization, thrombosis, or hemodynamic compromise. Carotid artery disease does not usually cause symptoms, but it can cause dizziness, strokes and transient ischemic. DIAGNOSIS • Carotid Duplex Ultrasound – This test uses sound waves to diagnose stenosis of the arteries. • Magnetic Resonance Angiography (MRA) – It works the same way as the MRI, with injection of a contrast that makes the arteries show up more clearly. • Computed Tomography Angiography (CTA) – It is CT scanning with contrast. MANAGEMENT The aim of treatment is to prevent stroke. This includes: Dr. Amany Serag Cardiologist people who have had a TIA or stroke and who have a lot of plaque in their carotid arteries. It is also appropriate for some people who have not had a stroke or TIA but who have a lot of plaque in their carotid arteries. • Carotid Stenting – This involves insertion of a tiny metal tube called a “stent” into the carotid artery to prop open narrowed arteries. The right treatment for each patient depends on: • If he had already a stroke or TIA . • How much of the carotid artery is blocked by the plaque • The age and gender of the patient • The presence of other health problems besides carotid artery disease (Hypertension, Diabetes Mellitus and Hyperlipidemia) Modern medical therapy that includes compliance with statins and anti-platelet agents, treatment of hypertension, diabetes and quitting cigarette smoking, has narrowed the gap between medical and surgical treatment of carotid disease for reducing the risk of stroke. • Lifestyle Changes – Risk of stroke can be reduced by: Quitting smoking if they smoke Being active Losing weight if they are overweight Eating a diet low in fat and cholesterol and high in fruits, vegetables, and low-fat dairy foods • Medicines – Different people need different medicines to reduce their chances of having a stroke. In general, the medicines that can help prevent strokes include: Antihypertensives - medicines that lower blood pressure. Medicines called statins, which lower cholesterol Medicines to prevent blood clots, such as aspirin • Surgery – For removal of the plaque from the carotid arteries. This is called “carotid endarterectomy.” This treatment is most appropriate for Visit our social media page 06 Stainless Steel Crowns In Paediatric Dentistry Dr. Bijosh Jose Paedodontist Stainless steel crowns (SSC) are prefabricated crown forms that are adapted to individual teeth and cemented with a bio-compatible luting agent. They are used to restore damaged milk teeth and newly erupted permanent molars. Types of Stainless Steel Crowns According to composition 1. Heat hardeneable Martensitic type. 2. Non heat hardeneable series Ferritic type. 3. The Austenitic types of chromium-nickel-manganese series and chromium- nickle series. According to Size Available in six sizes for deciduous teeth and permanent teeth. Sizes four and five are commonly used. According to Shape 1. Untrimmed These are neither trimmed or contoured, require a lot of adaptation and rarely used today. 2. Pre trimmed crowns They have straight, non contoured sides but are festooned to follow the gingival line. 3. Pre contoured crowns These are festooned and pre contoured but a minimal amount of festooning and trimming may be necessary. Where Are They Used • In children with extensive carious lesion and rampant caries cases • Teeth with developmental defects like hypoplasia or hypocalcification • Following pulp therapy in deciduous teeth • As an abutment for space maintainer • As a preventive restoration • In children with bruxism • Restoration of fractured primary molars • Correction of anterior cross bite Visit our social media page Crown Selection Crowns are selected according to the mesio-distal width of the tooth measured before tooth preparation. Correctly selected crown, prior to trimming and contouring should cover the tooth preparation and provide resistance to removal. Tooth Preparation and Crown Adaptation Tooth preparation is done to provide space for the crown, remove the caries and leave sufficient tooth substance for retention of crown. 1-1.5 mm occlusal reduction is done to provide space for metal crown, proximal reduction is done to clear the contact with the adjacent teeth and the buccal and lingual reduction to a minimal, to reduce the undercuts. The selected crown is tried on the tooth by placing it on the lingual side and rotating it towards the buccal side. The crowns should not extend 1mm beneath the gingiva and should not cause gingival blanching. Contouring of the crown is done with contouring pliers as this is important for the gingival health. Crimping of the margins of the crown is done using crimping pliers to adapt the crown to the prepared tooth. Crown is fixed to the prepared tooth using a luting cement. A window is made on the buccal surface of the crown to make it into an open faced stainless steel crown Concern About Exfoliation SSC does not interfere with the normal exfoliation of the primary teeth with the SSC and the primary teeth being exfoliated together. Once fitted stainless steel crowns rarely need to be replaced. In addition to providing full coverage of teeth weakened by large removal of tooth substance, SSC also protect from future carious attack especially in high caries risk children. 07 Mumps in Children The mumps virus causes an acute, self-limiting viral syndrome. Prior to the widespread use of an effective vaccine, mumps primarily occurred in young children attending primary grade school. Mumps is highly infectious and spreads rapidly among susceptible people living in close quarters. Mumps virus is typically transmitted by respiratory droplets, direct contact, or fomites . Infants less than one year rarely acquire mumps due to passage of maternal antibodies. The incubation period is usually 14 to 18 days from exposure to onset of symptoms. Mumps is frequently accompanied by a nonspecific prodrome consisting of low-grade fever, malaise, headache, myalgias, and anorexia. These symptoms are generally followed within 48 hours by the development of parotitis (swelling of the parotid gland), present in 95 percent of symptomatic cases of mumps. The more serious complications of mumps, such as meningitis, encephalitis, and orchitis, may occur in the absence of parotitis which can delay accurate diagnosis of the clinical syndrome. Orchitis: the most common complication of mumps infection in the adult male. Symptoms are characterized by the abrupt onset of fever from 39 to 41ºC and severe testicular pain, accompanied by swelling and erythema of the scrotum. Oophoritis: occurs in seven percent of post-pubertal girls. Dr. Germine Soliman Paediatrician features. Leukopenia, with a relative lymphocytosis, and an elevated serum amylase may be noted. Laboratory evidence supportive of a mumps diagnosis include : • A positive IgM mumps antibody • Significant rise in IgG titers between acute and convalescent specimens • Isolation of mumps virus or nucleic acid from a clinical specimen. TREATMENT Treatment is symptomatic and includes analgesics or antipyretics . Topical application of warm or cold packs to the parotid may also be soothing. Patients who have meningitis or pancreatitis with nausea and vomiting may require hospitalization for intravenous fluids. Patients with orchitis are also treated symptomatically with bed rest, nonsteroidal antiinflammatory agents, support of the inflamed testis, and ice packs. PREVENTION Prevention of transmission of mumps to others is dependent on early diagnosis, isolation of the infected patient, and immunization of susceptible exposed individuals. Two doses of MMR vaccine to be given at age of one year and five years or at age of 13 years if not taken at five years of age. Meningitis: the onset of meningitis is variable and can occur before, during, or after an episode of mumps parotitis; The most frequent manifestations are headache, low grade fever, and mild nuchal rigidity. Other neurologic complications are encephalitis, deafness, Guillain-Barré syndrome, transverse myelitis, and facial palsy . Less frequent complication linked to mumps infection include thyroiditis, myocardial involvement, pancreatitis, interstitial nephritis and arthritis . DIAGNOSIS When the patient has parotitis, the diagnosis of mumps is based upon the characteristic clinical Visit our social media page 08 Diabetic Retinopathy Dr. Khaled Galil Diabetologist Diabetic retinopathy is one of the most important causes of visual loss world-wide. it is the principal cause of impaired vision in patients between 25 and 74 years of age. Visual loss from diabetic retinopathy may be secondary to macular edema (retinal thickening and edema involving the macula), hemorrhage from new vessels, retinal detachment, or neovascular glaucoma. • The prevalence of retinopathy increases progressively in patients with both type 1 and type 2 diabetes with increasing duration of disease. • Retinopathy begins to occur in patients with type 1 diabetes three to five years after diagnosis and almost all patients were affected at 15 to 20 years. • The incidence of retinopathy in patients with type 2 diabetes is 50 to 80 percent at 20 years. Some have retinopathy at the time of diagnosis and perhaps some begin four to seven years before the clinical diagnosis of diabetes. This observation is primarily a reflection of the typically insidious onset of hyperglycemia and delayed diagnosis of type 2 diabetes. Diabetic retinopathy is divided into two major forms: non-proliferative (NPDR) and proliferative (PDR), named for the absence or presence of abnormal new blood vessels emanating from the retina. The severity of proliferative retinopathy can be classified as early, high risk, and severe. Macular edema can occur at any stage of diabetic retinopathy. It may be visualized by fundus examination with stereoscopic viewing, fluorescein angiography, and most directly by optical coherence tomography (OCT; a non-invasive low energy laser imaging technology). New vessels are categorized by four variables: presence, location, severity, and associated hemorrhagic activity. The vessels initially grow along the plane of the retina, under the posterior hyaloid or outermost layer of the vitreous body, but as the vitreous gradually pulls away and detaches from the retina, the new vessels grow out from the retina plane and into the vitreous cavity. The presence of Diabetic Retinopathy appears to be a marker of excess morbidity and mortality risk (primarily cardiovascular). Patients with NPDR or PDR have a greater risk of myocardial infarction and stroke, compared with those without retinopathy . Although the presence of other cardiovascular risk factors may explain the association, the risk of cardiovascular disease events remain two-fold higher in individuals with PDR, but not in those with NPDR, after adjustment for hypertension and nephropathy. Visit our social media page 09 Dental Braces for Adults Many adults with crooked teeth think they missed their opportunity for braces during childhood. However, Orthodontists now readily use braces to help correct dental problems at any age. Adult braces can be used to correct a variety of dental problems, including: • Crooked teeth • Overcrowded teeth • Bite abnormalities (an overbite or underbite) • Jaw joint problems Without proper treatment for these problems, you may be at higher risk of cavities, gum disease, ear pain, headaches, and chewing and speech problems. For this reason, braces can be an important part of the maintenance of your dental health. Some people shy away from braces because they want to avoid having a mouth full of metal. Fortunately, there are many teeth-straightening options available today, some of which are nearly invisible. Options for adult braces and alternatives to braces include: • Conventional Metal Braces. Conventional metal braces involve attaching metal brackets and wires to your teeth. The braces are periodically adjusted in order to apply pressure to your teeth in such a way that they move into proper position. While conventional metal braces are efficient and relatively inexpensive, they are not always the first choice among adults who want braces, since they are so noticeable. Dr. Suvil Wilson Orthodontist • Clear Acrylic Aligners. Clear acrylic aligners are custom-fitted, removable appliances that are placed over your teeth. The major advantages are that aligners are essentially invisible and are easier to clean than braces because they can be removed during eating. Also, some people may still end up briefly requiring regular braces after wearing aligners. Duration of Brace Use On average, most people need to wear braces for about two years. While you're wearing braces, you'll need to be extra vigilant about your dental hygiene. This will involve monthly visits to your orthodontist, regular dental checkup and brushing your teeth every time you eat to reduce the risk of getting food caught under your braces. After your braces have been removed, you will need to wear a retainer (a device that's fitted to your mouth to help keep your teeth in position) for a period of time to reinforce and preserve the new alignment of your teeth. Some retainers are worn permanently, though most are used for only a short time. Wearing your retainer as recommended is essential for the long-term success of your treatment. • "Clear" Ceramic Braces. Ceramic braces are similar to traditional braces, but their brackets are made of tooth-colored porcelain, and so only the connecting wires are visible. • Lingual Braces. These braces are attached to the back of the teeth, facing the tongue and, therefore, not visible. They can be, however, irritating to the tongue and may be more difficult for the orthodontist to adjust. Visit our social media page 10 Acute Prostatitis Dr. Yousry Hannah Urologist The prostate is subject to various inflammatory disorders. One of these is acute bacterial prostatitis, an acute infection of the prostate, usually caused by Gram-negative organisms. The clinical presentation is generally well defined, and antimicrobial therapy remains the mainstay of treatment. CLINICAL MANIFESTATIONS Patients are typically acutely ill, with spiking fever, chills, malaise, dysuria, irritative urinary symptoms (frequency, urgency, urge incontinence), pelvic or perineal pain, and cloudy urine. Men may also complain of pain at the tip of the penis. Swelling of the acutely inflamed prostate can cause voiding symptoms, ranging from dribbling and hesitancy to acute urinary retention. DIAGNOSIS The presence of typical symptoms of prostatitis should prompt digital rectal examination, and the finding of an edematous and tender prostate usually establishes the diagnosis of acute bacterial prostatitis. Digital rectal examination is performed gently; vigorous prostate massage is avoided since it is uncomfortable, allows no additional diagnostic or therapeutic benefit, and increases the risk for bacteremia. In patients who present with constitutional symptoms only, establishing a diagnosis of acute prostatitis is challenging. Laboratory findings of leukocytosis (high white cell count), pyuria (pus in urine), bacteriuria, or an elevated serum prostate specific antigen (PSA) level can support the diagnosis, and should prompt consideration of digital rectal examination. MANAGEMENT Treatment of acute prostatitis includes antimicrobial therapy and supportive measures to reduce symptoms. Rarely, more invasive intervention is indicated to manage complications, the most common being prostatic abscess formation. Not all patients with acute bacterial prostatitis warrant inpatient hospitalization. Patients who have no major signs or symptoms of severe sepsis, and who can reliably take and tolerate oral antibiotics, can likely be managed appropriately as an outpatient. A variety of antimicrobials may be used for the treatment of acute prostatitis, which should be treated empirically pending culture result. Empiric therapy are based on the likelihood of the infecting organism. Although not all antibiotics can penetrate into prostatic tissue, the presence of acute inflammation generally allows entry of drugs that would not otherwise achieve therapeutic levels. Visit our social media page 11 The Way Children Walk Dr. Khaled Zaki Paediatrician Gait is the word used to describe the way people walk. When children first learn to walk they do not walk in the same way as older children or adults. For example, they walk with their legs wide apart for balance, and their legs may not seem as straight as older children. Parents often worry about whether the way their child walks is normal. Often the way the child is walking is normal for their age and will change as they get older. Bow Legs / Knock Knees As children grow, alignment of their legs naturally changes. Babies are born with bow legs, but this is generally not noticed until they start to walk. Once the child starts to walk the legs begin to straighten. By three years of age, children often have a knock-kneed appearance. Knock knees are common in children three-eight years of age. Usually their legs become straighter by eight years of age. In-toeing / Out-toeing In-toeing is walking with one or both feet turned inwards. It is common in childhood, and can cause children to trip and fall more often than other children. The in-toeing may arise from the child's hips, leg bones or feet. Usually this becomes normal as the child grows older and no treatment is needed. Out-toeing is when the child walks with feet turned outwards. This is less common than in-toeing. Tip-toe Walking Toddlers often start walking up on their toes, and this usually changes in the first year of walking. Children who continue to walk on their toes as they grow should be checked by a specialist to detect the cause. Toe walking may be due to tight muscles in the child's legs, which can be helped with stretching exercises. Sometimes a short period in plaster casts can help to stretch the muscles and help the child to walk with heels on the ground. Flat Feet Parents are often concerned when their child's feet appear flat, but for most children it is a normal part of their development. Children usually have low arches because they are loose-jointed and flexible, and their arches flatten when they stand. When their feet are hanging free, or the child stands on tip toes the arches can usually be seen more clearly. Flat feet are common in pre-school children due to fat pads hiding the arches of their feet. As children grow, these fat pads appear smaller, and the arch can be seen more clearly. Visit our social media page 12 Keloid Keloid is benign fibrous growth present in scar tissue that forms because of altered wound healing, with overproduction of extracellular matrix and dermal fibroblasts. In some patients the resulting lesion is disfiguring and painful. Recurrence is common after treatment. The precise pathogenesis of keloid formation is unknown. For some reason, certain individuals, most commonly blacks, develop a hyperproliferation of fibroblasts in response to trauma or, less commonly, de novo. Any skin insult (eg, ear piercing, lacerations, secondarily infected skin lesions, surgery) can cause keloid formation in predisposed individuals. DIAGNOSIS This is based upon the clinical appearance of excessive scar tissue. Patients may be asymptomatic, but frequently have lesions that are itchy and tender to palpation. Most commonly keloids occur on the ears, neck, jaw, pre-sternal chest, shoulders, and upper back. Hypertrophic scars may initially appear similar to keloids, but in contrast to the latter, hypertrophic scars do not extend beyond the margins of the wound. While the treatment strategies are similar for both lesions, hypertrophic scars are far less likely to recur once treated. Dr. Mohamed El Sakka General Surgeon Silicone Gel Sheeting has been used for the treatment of symptoms (eg, pain and itching) in patients with established keloids as well as for the management of evolving keloids and the prevention of keloids at the sites of new injuries. The sheet is placed on top of the keloid, taped into place, and left on for 12 to 24 hours per day. The sheet is washed daily and replaced every 10 to 14 days. Effectiveness is judged after two to six months of therapy. Cryosurgery is most useful in combination with other treatments for keloids, although up to 50 percent of patients may respond to cryotherapy alone. The major side effect is permanent hypopigmentation, limiting its use in patients with darker skin. Pressure Ear-rings - Pressure therapy is an effective treatment for keloids of the ear following piercing. Radiation – Radiation therapy alone or in combination with surgery (post-operative radiation) is now an accepted modality for treatment of keloids. Laser Treatment – Pulsed dye lasers (PDL) are considered are the laser of choice for keloids and hypertrophic scars. TREATMENT The best treatment is prevention in patients with a known predisposition. A number of treatment options are available for painful or cosmetically disfiguring keloids: Intralesional Corticosteroids are first-line therapy for most keloids. 70 percent of patients respond to intralesional corticosteroid injection with flattening of keloids, although the recurrence rate is high (up to 50 percent at five years). Atrophy and hypopigmentation of skin may occur with high doses. Surgical excision is recommended if there is no response after four injections. Excision : Excision may be indicated if injection therapy alone is unsuccessful or unlikely to result in significant improvement. Excision should be combined with preoperative, intraoperative, or postoperative steroid or interferon injections. Visit our social media page 13 Disease Modifying Anti-Rheumatic Drugs Dr. Peter Farag Rheumatologist Disease modifying anti-rheumatic drugs (DMARDs) are a group of medications commonly used in patients with rheumatoid arthritis. They suppress the body's overactive immune and/or inflammatory systems. They reduce joint damage, preserve the structure and function of the joints and are not designed to provide immediate relief of symptoms as they take weeks/months to take effect. Some of these drugs are also used in treating other conditions such as ankylosing spondylitis, psoriatic arthritis, and systemic lupus erythematosus. The most common DMARDs are: Methotrexate, Sulfasalazine, Hydroxychloroquine, Leflunomide, Azathioprine. Methotrexate is used in low doses. It works to reduce inflammation and decrease bone damage. It is usually taken once per week as a pill, liquid, or injection. Common side-effects include upset stomach and a sore mouth. It can interfere with the bone marrow's production of blood cells. Liver or lung damage can occur, even with low doses and, therefore, requires monitoring. Sulfasalazine is used in the treatment of rheumatoid arthritis and for arthritis associated with ankylosing spondylitis and inflammatory bowel disease (ulcerative colitis and Crohn's disease). It may be combined with other DMARDs if a person does not respond adequately to one medication. It is taken as a pill twice per day, and is usually started at a low dose and increased slowly, to minimize side effects. Side effects include changes in blood counts, nausea or vomiting, sensitivity to sunlight, skin rash, and headaches. Periodic blood tests are recommended to monitor the blood count. Hydroxychloroquine was originally developed as a treatment for malaria but was later found to improve symptoms of arthritis. It can be used early in the course of rheumatoid arthritis and is often used in combination with other DMARDs. It is also often used for treatment of systemic lupus erythematosus. It can be combined with steroid medications to reduce the amount of steroid needed. It is usually taken in pill form once or twice per day. Taking a high dose for prolonged periods of time may increase the risk of damage to the retina of the eye. An eye examination is recommended before starting treatment and periodically thereafter. Leflunomide inhibits production of inflammatory cells to reduce inflammation. It is often used alone but may be used in combination with methotrexate for people who have not responded adequately to methotrexate alone or together with a biologic agent. It is taken by mouth once daily. Side effects include rash, temporary hair loss, liver damage, nausea, diarrhea, weight loss, and abdominal pain. Regular testing to monitor for liver damage is required. Azathioprine has been used in the treatment of rheumatoid arthritis. It is generally reserved for patients who have not responded to other treatments. The common side effects are nausea, vomiting, decreased appetite, liver function abnormalities, low white blood cell counts, and infection. It is usually taken by mouth once daily. Blood testing is recommended during treatment. Visit our social media page 14 Spinal Cord Injury Dr. Samy Gouda Neurosurgeon Traumatic spinal cord injury is a problem that largely affects young male adults as a consequence of motor vehicle accidents, falls, or violence. Most of these cord injuries occurs with injury to the vertebral column, producing mechanical compression or distortion of the spinal cord with secondary injuries resulting from ischemic, inflammatory, and other mechanisms. It may be associated with injury to brain, limbs, and/or viscera, which can obscure its presentation. The neurologic injury produced by spinal cord trauma is classified according to the spinal cord level and the severity of neurologic deficits. Half of these involve the cervical spinal cord and produce quadriparesis or quadriplegia (weakness or paralysis of all four limbs). Patients with acute spinal cord injury require admission to an intensive care unit for monitoring and treatment of potential acute, life-threatening complications, including cardiovascular instability and respiratory failure. Patients should receive prophylaxis to protect against deep venous thrombosis and pulmonary embolism. Indications for cervical spine surgery include significant cord compression with neurologic deficits, especially those that are progressive, that are not amenable or do not respond to closed reduction, or an unstable vertebral fracture or dislocation. Neurologically intact patients are treated non-operatively unless there is instability of the vertebral column. The initial evaluation and management of patients with spinal cord injury in the field and emergency department focuses on the ABCD (airway, breathing, circulation, and disability), evaluating the extent of injuries, and immobilizing the potentially injured spinal column. Patients with suspected spinal cord injury because of neck pain or neurologic deficits and all trauma victims with impaired alertness or potentially distracting systemic injuries require continued immobilization until imaging studies exclude an unstable spine injury. All patients with potential spinal cord injury should receive complete spinal imaging with plain X-rays or Computed Tomography (CT) scan. Magnetic resonance imaging (MRI) can be useful to further define the extent of cord injury and should be performed on patients suspected to have spinal cord injury (because of neck pain or neurologic deficits) despite a normal CT scan. Intravenous (IV) Methylprednisolone is administered for patients who present within eight hours of isolated, non penetrating spinal cord injury. The standard dose is 30 mg/kg IV bolus, followed by an infusion of 5.4 mg/kg per hour for 23 hours. Visit our social media page 15 Fight Stress with Healthy Habits www.heart.org Healthy habits can protect you from the harmful 10. Try Not to Worry. effects of stress. Here are 10 positive healthy habits The world won't end if your grass isn't mowed you may want to develop. or your kitchen isn't cleaned. You may need to do these things, but today might not be the 1. Talk with Family and Friends. right time. A daily dose of friendship is great medicine. Call or write your friends and family to share your feelings, hopes and joys. 2. Engage in Daily Physical Activity. Regular physical activity relieves mental and physical tension. Physically active adults have lower risk of depression and loss of mental functioning. Physical activity can be a great source of pleasure, too. Try walking, swimming, biking or dancing every day. 3. Accept the Things You Cannot Change. Don't say, "I'm too old." You can still learn new things, work towards a goal, love and help others. 4. Remember to Laugh. Laughter makes you feel good. Don't be afraid to laugh out loud at a joke, a funny movie or a comic strip, even when you're alone. 5. Give Up the Bad Habits. Too much alcohol, cigarettes or caffeine can increase stress. If you smoke, decide to quit now. 6. Slow Down. Try to "pace" instead of "race." Plan ahead and allow enough time to get the most important things done. 7. Get Enough Sleep. Try to get six to eight hours of sleep each night. If you can't sleep, take steps to help reduce stress and depression. Physical activity also may improve the quality of sleep. 8. Get Organized. Use "to do" lists to help you focus on your most important tasks. Approach big tasks one step at a time. For example, start by organizing just one part of your life — your car, desk, kitchen, closet, cupboard or drawer. 9. Practice Giving Back. Volunteer your time or return a favor to a friend. Helping others helps you. Visit our social media page 16