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Update July 2018

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Update by Natrakorn Paewsoongnern

Doctor's Consultation  by Dr. Iain Corness


July 21, 2018 - July 27, 2018

Sore throat – is it tonsillitis?

The crying child, tugging at its ear and running a high temperature is a common occurrence, and can be the signs of tonsillitis. Add to that a change in the child’s voice and you have almost a 100 percent chance that this is tonsillitis.

It is such a common complaint that most of us got our tonsils yanked when we were about three years old. However, adults can get tonsillitis too.

The tonsils are interesting little (or in some cases, not so little) glands. They live in the back of the throat and can become acutely infected which we call Acute Tonsillitis, or can carry a low grade infection for many months or even years, known as Chronic Tonsillitis.

The infecting organism is also of interest and can be a Virus, or Chlamydia, or bacteria such a Streptococcus or Staphylococcus, Mycoplasma, Fungi or Parasites. Another interesting snippet is that the most likely organism varies with the age of the owner of the rotten tonsils. In the 2-7 year olds it is Haemophilus influenzae which is the culprit, while in the 8-14 year olds it is Staphylococcus aureus and after that it becomes a mixed bag.

With an acute tonsillitis, when you look inside the mouth there will be two “strawberry” shaped masses in the back of the throat. They may even have little white follicles on them, like strawberries. They can get so big that they will even meet in the midline, displacing the uvula, the little ‘clapper’ that hangs down in the center of your throat. Pain radiating up to the ears is another frequent symptom, and the younger ones can run temperatures over 40 degrees C which is a worry for most Mums. Another symptom of an acute attack is bad breath, so if Junior can knock over the cat with one breath, have a look at his tonsils!

An appropriate antibiotic settles the acute attack fairly quickly, but it is very necessary to make sure the child takes the full course of medicine. With the more chronic attacks, the pain is less, the temperature is less, but the patient does not feel well, and antibiotic treatment is usual. Of course, it is necessary to identify the causative organism, and a tonsilar swab is usually taken to identify the nasty little blighter. It is also important to treat the other symptoms, such as pain and the elevated temperature, and paracetamol is the drug of choice for this.

When I was a child (in the days of hardship before ballpoint pens and cellophane paper) one good attack of tonsillitis was enough to have you prostrate under the surgeon’s knife, but these days we are a little more circumspect.

The US Center for Disease control recommends if there have been fewer than seven episodes of recurrent throat infection in the past year or fewer than five episodes per year in the past 2 years or fewer than three episodes per year in the past 3 years, watchful waiting is preferred over tonsillectomy.

Tonsillectomy is indicated for recurrent throat infection of at least seven episodes in the past year or at least five episodes per year for 2 years or at least three episodes per year for 3 years with documentation of one or more of the following: temperature above 38.3C, cervical glands enlarged, tonsillar exudate, and/or positive test for Group A -hemolytic streptococcus (GABHS).

Tonsillectomy may be considered in children who do not meet the above criteria but have multiple antibiotic allergies/intolerances, (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or a history of peritonsillar abscess.

So despite all our advances in pediatric medicine, tonsillitis is still with us, and will be for many years to come yet.

July 14, 2018 - July 20, 2018

Depressed again?

We are not positive all the time. We do, and naturally I might add, get depressed. Depression is unfortunately an integral part of life and living, and there cannot be many people who can say they have never been depressed in their lifetime. Does this mean we are all mentally disturbed? Fortunately, no!

The opposite of depression is elation and whilst we all sail between depression and elation (which we medico’s call Euphoria, just to be different), it is only when the mood stays down in the depths that it becomes a problem. So how much of a problem is it in the community?

When we begin to look at the various incidence rates the whole situation can become quite interesting. Did you know, for example, that women get depression twice as much as men, but the suicide rate for men is five times that for women? Did you also know that the World Health Organization (WHO) is predicting that by the year 2020 depression will be the major contributing factor to the burden of disease in the developing world (and that could be us, if the POTUS ever stabilizes)! What a depressing thought.

Other interesting facts emerging from the world-wide studies of depression in women, the highest rates of depression occur in the 18-24 year age group, while in men it peaks in the 35-44 year age group. Men really are from Mars and Women are from Venus perhaps?

Of course, the statisticians have managed to come up with other associations, which may or may not be relevant. Such as the statistic that 50 percent of people with depression also suffer from some physical problem or illness. For me, it is a case of the chicken and the egg. Which came first? Are these people depressed because they have an illness or does the depression make them more prone to illness, or does the illness cause the depression? The answer is probably a bit of all of them. For example, the risk of Ischemic Heart Disease (Angina and the like) is three times greater in men diagnosed as having depression, and it has also been found that depression is present in 45 percent of patients admitted to hospital with a heart attack. Chicken and the egg once more.

So what kind of person gets depression? Is there an algorithm we can use to pinpoint the depressives? The personality profile includes those who are “worriers”, perfectionists, shy and socially anxious, and those with low self-esteem. It also includes people with low thyroid function, infectious diseases, cerebral (brain) blood vessel disease through to diabetes and increased blood pressure, chronic pain and cigarette smokers. Smoking to settle yourself down may be sowing the seeds of depression.

Another interesting fact: The apparent differences between women and men may also be more imagined than real. That females report twice as much depression as males may be a reflection of the male upbringing, where boys are taught that it is “weak” to show their emotions, which subsequently results in under-reporting their symptoms, whereas women can express their emotions much better.

So what can be done about this depression epidemic? Fortunately modern treatment is producing some worthwhile drugs which can elevate the mood without making the person into a zombie. However, medication should not be thought of as the only way to go about it. A pocketful of pills and you are instantly better is not what happens. There should also be careful psychological assessment which takes time, and assistance given with the planning of activities, the sleep cycle and structured problem solving.

Early intervention is important too, so if you are getting depressed, now might be the time to do something about it by seeking professional help.

July 7, 2018 - July 13, 2018

Sticks and stones may break my bones

My son fell over at school and when I went to pick him up he was holding his right wrist tightly and said, “Daddy it is the biggest pain I’ve ever had.” With that simple presentation, I knew he had a fracture of his wrist. A visit to my hospital’s X-Ray department confirmed my suspicion regarding a ‘greenstick fracture’ and so he was put in plaster to immobilize the bone and its fracture.

Broken arms are always in vogue, with two of my friends fracturing theirs, as well as number 1 son. One fell off his bicycle, while pedaling to get fit, and the other managed to get center-punched by another motorcycle while riding his to work. Neither has relished the experience, and all three have suffered pain.

Now whilst all three suffered breaks, or fractures as we medicos call them, there are various degrees and types you can end up with. Son and friend number one were the luckiest, suffering “hairline” fractures of the Radius (the larger of the two bones in the forearm). This should be thought of as more of a “crack” in the outer surface of the bone, just like you can pick up a drinking glass and see that it is cracked, but not broken in half. However, it is still a painful condition, and the extreme bruising that came out on the arm over the following ten days showed the amount of trauma involved in stepping ungracefully off a bicycle!

The treatment for this type of fracture is fairly conservative. A splint for a couple of weeks to rest the arm, some anti-inflammatories to reduce the swelling and some simple pain killers. After three weeks, this type of fracture will be satisfactorily healed, though it does take around six weeks for total healing.

Friend number two was not so lucky. Picking himself up off the road he noticed that there was the end of a piece of bone sticking out through the skin on his forearm, and as he so aptly said, “It’s a scary feeling seeing your own bones!” Now this is a real fracture, with complete division of the bone, and when it sticks through the skin we called it a “compound” fracture. Raw jagged ends certainly “compound” the problem!

Treatment for one of these is more than a simple case of immobilization. What is called an Open Reduction under general anesthesia is required. In other words, you are put to sleep, so that the orthopedic surgeon can get in and close the fracture. In this case, as with most of these, it is also necessary to insert a metal plate into the arm, which is screwed firmly to the two halves of the bone. This internal fixation holds the bone ends together and a cast over the outside of the arm then completes the physical treatment side of it. Of course, after surgery it is necessary to have some fairly potent pain killers, and generally we would prescribe some antibiotics as well.

Around three weeks, the cast can be thrown away, and after six weeks, the patient can usually use the afflicted limb quite well. With many of these, we also go back in after one to two years and remove the plate and screws.

Sometimes, we actually fix the two halves of bone by screwing an external plate through the skin and into the bone itself. This is called “external” fixation and you don’t need a secondary operation to remove the plate - but it does mean you put up with something that looks like scaffolding around your broken limb.

So what do you do when presented with something that might be a fracture? The simplest and best first aid you can do is to immobilize the fracture by splinting the limb involved. Wrap a magazine around the arm and hold in place with a crepe bandage.

With compound fractures, a sterile pad over the fracture and a gently applied crepe bandage over that and a trip to hospital.

The elderly should try not to fall as old bones are not as strong as young ones, and a fracture of the neck of femur (thigh bone) may be dangerous.

June 30, 2018 - July 6, 2018

Appendicitis - a pain in the belly!

Since the appendix is a vestigial organ, I often get asked why do we still have an appendix. Please note, the appendix is singular, you don’t have “them” removed. My answer is that it is actually a very important organ, as it is the first surgical procedure done by new surgeons. Yes, my first was a Russian seaman in Gibraltar, and I think I was much more worried and apprehensive than he was, but that is a yarn for another time.

A few years ago now, one of my friends was rushed to hospital with inflammation of the appendix, which we medico’s call appendicitis (remember that “-itis” at the end of the word usually means inflammation). He had noticed some pain previously and a watchful eye was being kept upon him by the surgeon, waiting to see if it would “blow up” (not in the bomber sense) or subside. It didn’t settle and as the pain became acute he ended up on the table and sacrificed his inflamed organ (the appendix, silly!) to the surgeon’s knife. If it makes you feel better, there are no ‘apprentice’ surgeons at my hospital!

The appendix is a little “finger” shaped appendage that hangs off the bowel and connects with it. Ruminants such as cows have large ones, if size really matters! For us, it is also one of those cute “vestigial” organs which has no apparent functional use these days, but can give us lots of problems if things go wrong. And things often do go wrong, with appendicitis being experienced by about 1 person in 500 every year. Males suffer from this more than females and it can strike at any age, though under two is exceptionally rare. The most affected age group is between fifteen and twenty-four.

So what causes Appendicitis? It is a form of infection which is generally from the food passing through the gut and can be bacterial or even viral. Sometimes the poo (nice medical term) in the gut gets jammed into the appendix and causes the initial problem. Just for the record, we call it inspissated feces, just to make it sound grander than it really is.

While the signs and symptoms of Appendicitis are straightforward, the diagnosis is not as easy as a number of other abdominal conditions will mimic the symptoms of centro-abdominal pain which radiates to the right iliac fossa, nausea, with a low grade fever and occasional diarrhea. From my medical student days I can even remember the last one being the Abdominal Crises of Porphyria! I must admit that in 50 years of medicine I’ve never met her!

There are some laboratory tests which can be done, especially a blood test to see if the White Cell count has gone up, and some centers will perform ultrasound to try to differentiate what is going on inside the belly.

The definitive “cure” is to whip out the offending organ, and as mentioned before, this is usually one of the first operations a young first year surgeon does on his own.

My old surgical boss always told me to make sure the skin incision was as small and as neat as possible, because that was all the patient had to go by to judge one’s competency. It didn’t matter what went on inside - just make sure the outside looked good! This was particularly important with young females and a 2 cm scar level with the top of the bikini bottom was the ideal.

However, these days most surgical removals are done via “keyhole” surgery with three or four small incisions only. The recovery time after this form of surgical procedure is also quicker than “open” surgery.

Post-operatively the vast majority of patients do well and are up and about in a few days, happily living without their appendix, so if you’re having some grumbling gut pains, and you still have your Appendix, perhaps you should let our doctors cast their practiced eyes over it.

HEADLINES [click on headline to view story]

Sore throat – is it tonsillitis?

Depressed again?

Sticks and stones may break my bones

Appendicitis - a pain in the belly!



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