Sunday, March 27, 2011

Appendicitis

Appendicitis is a condition characterized by inflammation of the appendix. It is a painful swelling and infection of the appendix.It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy.
Causes
Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected. Sources of obstruction include
• Feces, parasites, or growths that clog the appendiceal lumen
• Enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal tract or  elsewhere in the body
• Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
• Trauma to the abdomen
Symptoms
Most people with appendicitis have classic symptoms that a doctor can easily identify. The main symptom of appendicitis is abdominal pain.
The abdominal pain usually
• Occurs suddenly, often causing a person to wake up at night
• Occurs before other symptoms
• Begins near the belly button and then moves lower and to the right
• Is new and unlike any pain felt before
• Gets worse in a matter of hours
• Gets worse when moving around, taking deep breaths, coughing, or sneezing
Other symptoms of appendicitis may include
• Loss of appetite
• Nausea
• Vomiting
• Constipation or diarrhea
• Inability to pass gas
• A low-grade fever that follows other symptoms
• Abdominal swelling
• The feeling that passing stool will relieve discomfort
Symptoms vary and can mimic other sources of abdominal pain, including
• Intestinal obstruction
• Inflammatory bowel disease
• Pelvic inflammatory disease and other gynecological disorders
• Pntestinal adhesions
• Constipation
Diagnosis
For the most part, symptoms are related to disturbed bowel functions. Pain first, vomiting next and fever last has been described as classic presentation of acute appendicitis. Pain starts mid abdomen, and except in children below 3 years, tends to localize in right iliac fossa in a few hours. This pain can be elicited through various signs. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix.
Physical Examination
Details about the abdominal pain are key to diagnosing appendicitis. The doctor will assess pain by touching or applying pressure to specific areas of the abdomen.
Responses that may indicate appendicitis include
Psoas sign
Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with the patient extending the hip due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes the pain because it stretches the muscles, and flexing the hip into the "fetal position" relieves the pain.
Dunphy's sign
Increased pain in the right lower quadrant with coughing.
Bartomier-Michelson's sign
Increased pain on palpation at the right iliac region as patient lies on his/her left side compared to when patient was on supine position.
Aure-Rozanova's sign
Increase pain on palpation with finger in right Petit triangle typical in retroceacal position of the appendix.
Blumberg sign
Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes the severe pain on the site indicating positive Blumberg's sign and peritonitis.
Obturator sign
The right obturator muscle also runs near the appendix. Tests for the obturator sign by asking the patient to lie down with the right leg bent at the knee. Moving the bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the appendix is inflamed.
Laboratory Tests
Blood tests are used to check for signs of infection, such as a high white blood cell count. Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children and shows free fluid collection in right iliac fossa along with a visible appendix without blood flow in color Doppler


CASE
This is the case of a boy [H. R.] aged 13 years old. He came to me with his parents for acute pain in abdomen with vomiting he had fever, tenderness RIF on physical examination. Thirst for large quantity of water. Pain aggravate by motion. He advised for USG abdomen.
USG report was 6.5 mm calculi in left middle calyx. RIF showing distended appendix with impacted faecolith of outer wall 5.8 mm inner lumen 8.4 mm surrounded by free fluid around it. s/o probe tenderness +++.ACUTE APPENDICITIS.
On 19/02/11 he was prescribed R-1, R-38, PYROGENUM, BRYONIA, MERC. SOL.
He came back after seven days on 27/02/11with no pain, no tenderness, no vomiting. He advised for USG. Repeat the same medicines.
On 06/03/11 USG report was few thick walled gut loops are seen in the abdomen. Repeat same as above.
He came back on 12/03/11 he was given following medicines R-37, bryonia, merc. Sol, nux. Vom,pyrogenum. He also advised for USG.
ON 19/03/11 He came with USG report. Report was probe tenderness absent, RIF appendix could not be visualized probebbly reterococel. He was cured.


Dr. G. S. Bhatnagar
D.H.M.S. B.H.M.S.
Research officer
Sewa Mandir
Mobile: 9829978284
E-Mail: sewamandir@usa.net, drgsbhatnagar@gmail.com

Wednesday, March 23, 2011

Radiations, their Effects and Management

This is the first article in the series of articles on Radiations and their effects for public awareness. The series is dedicated to each person who is exposed or suffering or has suffered the radiation exposure.

We all face risks in everyday life. It is impossible to eliminate them all, but it is possible to reduce them. The use of coal, oil, and nuclear energy for electricity production, for example, is associated with some sort of risk to health, however small. In general, society accepts the associated risk in order to derive the relevant benefits. However, the risk should be reduced to the lowest possible limit.
Radiation is hazardous in many ways. Man made radiations are the most destructive in the sense that the natural radiations occur as per the laws of nature but man sometimes, has no control over his own creation as the laws related to it are not fully understood nor the effects have been anticipated and studied! Even at the onset when radioactive elements were discovered certain firms in America started selling them as a tonic and in spite of warning from scientist people took them until their disastrous effects were discovered. The radiation has immediate as well as remote disastrous effects on life and living. Besides the socio-psychological effects, effects on health are the most important aspect to be considered.


Radiation in Everyday Life

Radioactivity is a part of our earth – it naturally exists almost everywhere. Radioactive materials are present in earth crust, the floors and walls of all buildings - houses, schools or offices and in the food articles and drinks. The air we breathe contains radioactive gases. Man’s own muscles, bones and tissues contain naturally occurring radioactive elements. Thus, man has always been exposed to natural radiation. The radiations received from outer space are called cosmic radiations or cosmic rays.
There is also an exposure from man-made radiation, such as X-rays, radiation used to diagnose diseases and for cancer therapy beside the daily use of electronic equipments as computer, laptop, cell-phone etc. Fallout from nuclear explosives testing, and small quantities of radioactive materials released to the environment from coal and nuclear power plants, are also sources of radiation exposure to man.
The term radioactivity describes disintegration of atoms. The atom is formed by the number of protons and neutrons in the nucleus and electrons moving around it. The nuclei of some natural elements are unstable hence disintegrate thus release energy in the form of radiation. This physical phenomenon is called radioactivity. The unit of radioactive decay is becquerels. One becquerel equals one disintegration per second.
The rate of decay of radionuclides (nuclii of radioactive atoms) remains constant and uninfluenced by temperature or pressure. The time that it takes for half the radionuclides to disintegrate or decay is called its half-life. This differs for each radioelement, ranging from fractions of a second to billions of years. For example, the half-life of Iodine 131 is eight days, but for Uranium 238, which is present in varying amounts all over the world, it is 4.5 billion years. Potassium 40, the main source of radioactivity in human bodies, has a half-life of 1.42 billion years.

Various Types of Radiation

The term "radiation" is very broad but for its effect on human mainly "ionizing" radiation is considered because such radiations pass through matter to cause it to become electrically charged or ionized. These electrical ions produced by radiation can affect normal biological processes.
Each type of radiation has different characteristics. The common ionizing radiations are:
Alpha radiations are heavy, positively charged particles emitted by atoms of radioactive elements such as uranium and radium. Alpha radiation can be stopped completely by a sheet of paper or by epidermis (the thin surface layer of our skin). If alpha particle emitting materials are taken into the body by breathing, eating, or drinking, the directly expose internal tissues may be biologically damaged.
Beta radiation consists of electrons are more penetrating than alpha particles and can pass through 1-2 centimetres of water. A few millimetres thick sheet of aluminum will stop beta radiation.
Gamma rays are electromagnetic radiation similar to X-rays, light, and radio waves. Gamma rays, depending on their energy, can pass right through the human body, but can be stopped by thick walls of concrete or lead.
Neutrons are uncharged particles, do not produce ionization directly. But, their interaction with the atoms of matter can give rise to alpha, beta, gamma, or X-rays which then produce ionization. Neutrons are penetrating and can be stopped only by thick masses of concrete, water or paraffin.
Although radiation cannot be seen or felt, it can be detected and measured in the minutest quantities with simple radiation measuring instruments.

Radiation Dose and Sources

We feel warmth of sunlight because our body absorbs the infra-red rays from it. But, they do not produce ionization in body tissue. The ionizing radiation impairs the normal functioning of the cells or kills them. The amount of energy necessary to cause significant biological effects through ionization is so small that our bodies cannot feel this energy as in the case of infra-red rays which produce heat.
The biological effects of ionizing radiation vary with the type and energy. The risk of biological harm is measure by the dose of radiation that the tissues receive. It is measured in millisievert (mSv) or microsievert (µSv) which are one-thousandth or one millionth of a sievert unit. For example, one chest X-ray will give about 0.2 mSv of radiation dose.
On average, radiation exposure for a person from all natural sources amounts to about 2.4 mSv a year - though this varies on different the geographical locations by several hundred percent.
The radioactive elements radon (Radon 222), thoron (Radon 220) and by-products formed by the decay of radium (Radium 226) and thorium present in many sorts of rocks, other building materials and in the soil. But the largest source of natural radiation is varying amounts of uranium and thorium in the soil around the world.
The radiation exposure due to cosmic rays dependents on altitude and slightly on latitude: people who travel by air are more exposed to cosmic radiation.
Internal exposure occurs from radioactive elements taken into body through food, water and through the air we breathe. In addition, radioactive elements (Potassium 40, Carbon 14, Radium 226) are always present in blood or bones.
Additionally, we are exposed to varying amounts of radiation from sources such as dental and other medical X-rays, industrial uses of nuclear techniques and other consumer products such as luminized wrist watches, ionization smoke detectors, TV, Computers, cell-phones etc. and the most dangerously exposed to radiation from radioactive elements contained in fallout from nuclear explosives testing and routine normal discharges from nuclear and coal power stations.

Protection from Radiation

The International Commission on Radiological Protection (ICRP) recommends that any exposure above the natural background radiation should be kept at lowest level reasonably achievable and below the individual dose limits. The individual dose limit above the natural background for radiation workers averaged over 5 years is 100 mSv, and for members of the general public, is 1 mSv per year. Any additional dose will cause a proportionally increase the chances of effecting health.
There are many high natural background radiation areas around the world where the annual radiation dose received by members of the general public is several times higher than the ICRP dose limit for the radiation workers but the numbers of people exposed are too small to expect to detect any health effects epidemiologically. Still there is no evidence that any increase does not mean the risk is being totally disregarded. Good radiation protection practice can result in low radiation exposure to workers.

Effects of radiation –

A very large dose to the whole body for a short period of time will cause death of the exposed person within days.
Some of the health effects occur when quite a large dose on exposure to radiation is absorbed. However, many other effects, especially cancers are readily detectable and occur more often with moderate doses for prolonged period.
At lower doses and dose rates cells and tissues recover to some degree but the overall effect is uncertain. It is presumed that at the exposure levels of natural background some additional risk of cancer is involve though there are thousands of carcinogenic substances in our everyday life besides radiation. They include tobacco, tobacco smoke, ultraviolet light, asbestos, some chemical dyes, fungal toxins in food, viruses, and even heat. It is generally not possible to identify conclusively the cause of a particular cancer.
There is also experimental evidence from animal studies that exposure to radiation can cause genetic effects. However, the studies of the survivors of Hiroshima and Nagasaki, so far give no indication of this for humans.
With all the knowledge so far collected on effects of radiation, there is still no definite conclusion as to whether exposure due to natural background carries a health risk, even though it has been demonstrated for exposure at a level a few times higher.


Risks verses Benefits

We all face risks in everyday life. It is impossible to eliminate them all, but it is possible to reduce them. The use of coal, oil, and nuclear energy for electricity production, for example, is associated with some sort of risk to health, however small. In general, society accepts the associated risk in order to derive the relevant benefits. Any individual exposed to carcinogenic pollutants will carry some risk of getting cancer. Strenuous attempts are made in the nuclear industry to reduce such risks to as low as reasonably achievable.
Radiation protection sets examples for other safety disciplines in two unique respects:
 First, there is the assumption that any increased level of radiation above natural background will carry some risk of harm to health.
 Second, it aims to protect future generations from activities conducted today.
The use of radiation and nuclear techniques in medicine, industry, agriculture, energy and other scientific and technological fields has brought tremendous benefits to society. The benefits in medicine for diagnosis and treatment in terms of human lives saved are enormous. Radiation is a key tool in the treatment of certain kinds of cancer. Three out of every four patients hospitalized in the industrial countries benefit from some form of nuclear medicine. The beneficial impacts in other fields are similar.
No human activity or practice is totally devoid of associated risks. Radiation should be viewed from the perspective that the benefit from it to mankind is less harmful than from many other agents.


Dr. M. K. Tyagi
D.H.M.S., Dip. N.I.H.Research Officer
Sewa Mandir
Mobile" 09829157926
Email: 1.sewamandir@usa.net, 2.manju_mkt2003@yahoo.co.in

Friday, March 11, 2011

Lactose Intolerance

Lactose is the major sugar found in milk and milk products. Lactose intolerance is the inability of a person to digest significant amounts of lactose (e.g. 250 ml of milk).
Lactose intolerance is caused due to lack of enzyme lactase produced by the cells of the small intestine. Lactase converts lactose into the simple forms of sugar, glucose and galactose, which can be absorbed and used by the body.

Infants have the highest levels of lactase to digest their mother's milk but in about 75% of people by adolescence lactase levels irreversibly decrease after weaning, due to a genetic trait. By adulthood, lactase activity is almost lost still not everyone has symptoms of lactose intolerance after consuming normal amounts of lactose.

Whether or not people develop symptoms appears to be linked to the ability of a certain type of beneficial intestinal bacteria, called lactic acid bacteria, to break down lactose. Some people may have more lactic acid bacteria in their intestines than others, so they don’t develop symptoms.

People who develop symptoms are said to have lactose intolerance.

Symptoms –
• Gas
• Cramping
• Abdominal pain
• Nausea
• Bloating
• Diarrhea
The undigested Lactose in the intestines causes diarrhea, because of the excessive amount of water that is drawn into the intestines by lactose. The undigested lactose in the colon (the large intestine) is broken down by bacteria into Lactic acid and other acidic chemicals. It is these products that create the symptoms of lactose intolerance. Hydrogen is produced, causing gas and bloating. These symptoms may occur 30 minutes to two hours after ingesting lactose-containing foods or late as it takes more than four hours for any food to reach colon. The severity of symptoms usually depends on the amount of lactose ingested and how much of the enzyme, lactase, remains in the intestinal tract.

Diagnosis – Do-It-Yourself Test - Since lactose intolerance is not a serious disorder, people test themselves at home. First, avoid milk and lactose-containing foods for several days. Then on a holiday morning drink two large glasses of skim or low-fat milk (400 – 500 ml) and take nothing else. If symptoms develop within four hours, the diagnosis of lactose intolerance is fairly certain.
In most cases the physician diagnoses simply by reviewing the patient's medical history. However, to make a definitive diagnosis, one of several tests may be needed:

Lactose Tolerance Test - A test dose of lactose is ingested and blood sugar determinations are made over several hours. If lactase is present to break down the lactose, then the blood sugar level rises. If the blood sugar level does not change means no lactase is present.

Hydrogen Breath Test - When lactose is broken down by the colonic bacteria, hydrogen is released, which then passes out through the lungs. The amount of hydrogen released after a lactose meal can indicate the problem.

Stool Acidity Test - When lactose breaks down to lactic and other acids in the colon, the resulting acidity can be detected by a simple measurement of stool acidity.
In cases of recently developed lactose intolerance it is important to consult with physician. Lactose intolerance can also be caused by medications or by an underlying condition that damages cells lining the intestines, such as:
• Crohn's disease
• Celiac disease
• Giardiasis
• HIV enteropathy
• Carcinoid Syndrome
• Diabetic gastropathy
• Zollinger-Ellison syndrome
• Alcoholism
• Iron Deficiency

Treatment –
Homoeopathic Medicines – There are many homoeopathic medicines indicated in milk and dairy product intolerance and symptoms arise as a result of it. For successful prescribing a particular medicine in a particular situation Law of similia is to follow. However, some of the symptomatically indicated medicines are listed here –
Acid nitricum, Aethusa cyn., Angustra vera, Belladona, Bryonia, Bufo, Calcarea carb., Carbo veg., China, Conium, Cuprum met., Iris ver., Lac – defloratum., Lycopodium, Magnesium carb., Magnesium mur., Magnesium sulph., Natrum carb., Raphanus, Silicea, Sulphuric acid, Sulphur are a few but other medicine may be found indicated.
If diarrhea, flatulence and distention is prominent Carbo veg. or Conium should tried.
Crampy pain indicates Sulphur, Lac defloratum, Bufo, magnesium sulph. and Nitric acid.

Diet – As digestion of lactose depends mostly on the bio-environment of intestines, some of the dietary measures very effectively keep the condition under control. For mild symptoms avoiding large amounts of milk and milk products may be enough. Those who are very sensitive to small amounts of lactose should check all foods carefully for lactose. Items such as bread, baked goods, cereals, instant potatoes (packed and ready to cook), soups, margarine, lunchmeat, salad dressings, pancakes, biscuits, cookies, and candy can contain certain amount lactose. Even certain drugs and Homoeopathic medicine may contain lactose.
Milk is a major source of calcium and calcium is necessary for good health and strong bones. Normal requirement is 1000 mg of calcium a day but pregnant and nursing females require 1200 mg per day and post-menopausal females 1500 mg per day. So, sometimes calcium supplement is required.

Some dietary strategies for people with lactose intolerance include:
• Drink one cup or less of milk at a time
• Eat milk and milk products with meals rather than alone
• Try reduced-lactose milk
• Try yogurt (known as curd in India) instead of milk
• And the most important is to add sufficient green vegetables in daily diet. Green turnip and leaves, broccoli (fresh phool gobhi and its leaves), cabbage and other green leafy vegetable can fulfill about 50% of daily requirement.


Acidophilus and Probiotics
(Probiotics are defined as ‘mono- or mixed cultures of live micro-organisms which, when applied to animal or man, beneficially affect the host by improving the properties of the indigenous microflora.)

Acidophilus is one of the lactic acid bacteria in the intestines which break lactose down into short-chain fatty acids and other substances that can be absorbed by the colon.

Lactic acid bacteria are available as dietary supplements in the form of capsules, tablets, or powders.
The bacteria commonly used for lactose intolerance include:
• Lactobacillus acidophilus
• Lactobacillus bulgaricus
• Streptococcus salivarius
• Lactobacillus reuteri
• Lactobacillus plantarum
• Streptococcus thermophilus

Studies have found that probiotics reduced breath hydrogen levels but not in all cases. Same is the case with the symptoms studies show both positive as well as negative results. A significant reduction in symptoms may be possible if the right type of bacteria in the right amount is used.

Yogurt (Dahi or popularly called Curd in India) -
Although yogurt is a milk product, many people with lactose intolerance do not experience symptoms after eating yogurt, even the kind that doesn't contain live active bacteria. Bile acids disrupt the bacterial cell wall thus release the enzyme beta-galactosidase (related to lactase) which enhances lactose digestion in the intestines.

Acidophilus Milk
Acidophilus milks are made by adding Lactobacillus acidophilus to cold milk. Though many studies have found no improvement in lactose digestion with it, may be due to insufficient amount of bacteria.

Lactase Supplements – Lactase supplements are only needed for larger quantities of lactose. Tablets containing lactase can be taken with lactose-containing foods.

Dr. M. K. Tyagi
D.H.M.S., Dip. N.I.H.Research Officer
Sewa Mandir
Mobile" 09829157926
Email: 1.sewamandir@usa.net, 2.manju_mkt2003@yahoo.co.in

Thursday, March 3, 2011

Hypothyroidism

Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone or Hypothyroidism is a deficiency of thyroid hormone in humans. Iodine deficiency is the most common cause of hypothyroidism but it can be caused by other causes such as several conditions of the thyroid gland, or less commonly, the pituitary gland or hypothalamus.
Signs and symptoms
            Hypothyroidism can be associated with the following symptoms:
Early
Late

Uncommon
Cause
The most common cause of hypothyroid is iodine deficiency.                                           Hypothyroidism is often classified by association with the indicated organ dysfunction.
 
Type 
Origin
Description
Primary
The most common forms include Hashimoto's thyroiditis and radioiodine therapy for hyperthyroidism.
Secondary
Occurs if the pituitary gland does not create enough thyroid-stimulating hormone (TSH) to induce the thyroid gland to produce enough thyroxine and triiodothyronine.
Tertiary
When the hypothalamus fails to produce sufficient thyrotropin-releasing hormone (TRH). TRH prompts the pituitary gland to produce thyroid-stimulating hormone (TSH). Hence may also be termed hypothalamic-pituitary-axis hypothyroidism.
Diagnosis Signs and tests
·         Increased liver enzymes
·         Increased prolactin
·         Low sodium
·         Free triiodothyronine (fT3)
·         Free levothyroxine (fT4)
·         Total T3
·         Total T4
Additionally, the following measurements may be needed:
  • 24-Hour urine-free T3
  • Antithyroid antibodies — for evidence of autoimmune diseases that may be damaging the thyroid gland
  • Serum cholesterol — which may be elevated in hypothyroidism
  • Prolactin — as a widely available test of pituitary function
  • Testing for anemia, including ferritin
  • Basal body temperature
      A physical examination may reveal a smaller than normal thyroid gland, although sometimes the gland is normal size or even enlarged (goiter). The examination may also reveal:
·         Brittle nails
·         Coarse facial features
·         Pale or dry skin, which may be cool to the touch
·         Swelling of the arms and legs
·         Thin and brittle hair
      A chest x-ray may show an enlarged heart.

Case
          Mrs. P.P. came to see me for hypothyroidism. It was a diagnosed case of hypothyroidism. Her TSH was 6.88 uIU/ ml.

On 29/01/2010 following medicines was prescribed. SPONGIA, IODIUM, KALI.CARB,ADEL-6 for two months.

On 02/04/2010 she was came with her TFT report.  Report was normal. The report was T3-0.91, T4-7.20, TSH-4.50.TFTwas normal. She was prescribed P. L. doses for two months.
She was come back on 29/06/10 with swelling, irregular menses. She was advised for TFT.
T3-68.8, T4-5.56, TSH-14.88. Again prescribed following medicines for three months. SPONGIA, IODIUM, KALI. CARB, ADEL-6
She came on 08/10/2010 with report of TFT which was normal.
T3-105, T4-5.61, TSH-2.61
We prescribed same medicines for three months

On 25/02/2011she came with no swelling, no palpitation, menses are regular and her TFT was normal. TSH 2.25uUI/ml.
P.L. doses prescribed
cured.

Dr. G. S. Bhatnagar
D.H.M.S.  B.H.M.S.
Research officer
Sewa Mandir
Mobile 9829978284