Second Opinion

SLMC: Time for the sleeping giant to awaken

Medical education in this country has always been a privilege. In terms of parental expectation, gaining entry to a medical faculty is still the ultimate goal in many families. This is so because the practice of medicine is considered a noble profession and Sri Lankan society still retains a sense of respect towards doctors though that dignity appears to have diminished somewhat in recent times.

The medical profession too has zealously- and sometimes jealously- guarded their standards which is why there were numerous disputes within the profession, firstly over the setting up of a privately-run medical college and then over the influx of foreign medical graduates to this country.

We believe those protests originated with a genuine desire to maintain professional standards at a high level. If that is indeed the case, then the time has now come to turn the searchlight inwards- towards our own medical schools- with regard to plans to expedite the intake of medical students to state medical faculties- taking two batches a year to clear a backlog that has accumulated over the years.

The stated objective is noble- to cut down the length of time students spend languishing at home after their Advanced Level examinations. But it appears that a decision has been made to hasten their entry into the medical faculties without looking into the problems faced by the medical schools.

Most universities are understaffed and overcrowded with students. Most still have the same facilities that existed twenty years ago. At best, the facilities have improved only marginally while the student population has grown exponentially. And, even with the regular intake of medical students, these resources have been stretched to the limit. Now, these halls of learning have been virtually ordered to double their workload.

To accommodate such a request, no doubt compromises will have to be made.

Facilities most importantly clinical teaching facilities in hospitals-for each student will be lesser and curricula will have to be amended. Quantity, it seems has taken precedence over quality. But then, this is the training of doctors, who will someday be dealing with patients' lives. So, does the end justify the means? We do not know at what level this decision was taken. In the past we have had politicians ordering the creation of medical faculties-both state and private- with disastrous consequences. We hope that this is not yet another of those politically motivated decisions.

Nevertheless, there is a body empowered to monitor medical education in this country- the Sri Lanka Medical Council. Perhaps it is now time for this sleeping giant to awaken and inspect these manipulations in medical education before the careers of thousands of budding doctors are compromised- yet again.

What parents need to know about asthma

The wheeze kids

Despite recent medical advances asthma re-mains a common problem in children, and therefore a constant source of worry for parents who often wonder when the next attack will occur.

In Sri Lankan medical practice it is a major cause of hospitalisation among children and that is at least partly due to poor parent education regarding the illness. But asthma is by and large preventable to some extent and that is what most parents do not seem to know.

The main indicators of asthma are wheezing, shortness of breath and chest tightening. A chronic cough is another big clue, especially if there is no obvious cause. While it's not unusual for toddlers to have runny noses, parents should pay attention to a nose that is always running, as this could be a signal that the airway tissues are producing too much mucus.

Parents should also be aware that the disease has hereditary links, so if it is known to run in their families, any of these symptoms could be a good reason to ask a doctor about asthma.

There are two main types of asthma medication: one for preventing attacks, another for on-the-spot treatment when the disease flares up.

Anti-inflammatory inhalers are used frequently to prevent asthma attacks.

These are usually based on steroid compounds and current research indicates that steroids offer the best long-term treatment, although there are non-steroid medications available as well.

For sudden episodes that can be brought on by a host of environmental triggers, doctors recommend also keeping bronchodilators on hand to rapidly open the airways. These are considered rescue medications, and using them frequently may indicate the need to modify a patient's anti-inflammatory medication or consider a higher dosage.

People with asthma can be hypersensitive to toxins such as cigarette smoke and smog and are often allergic to a wide variety of common particles found in dust, pet fur, and even cockroaches. Cold, damp weather or exercise may also bring on an asthma episode.

Finally, if a child known to have asthma is showing difficulty in breathing don't take chances and "wait and see". Many children still die of asthma, simply because of delayed treatment. Seek medical help- and do it soon!

The wonder drug Viagra

Viagra is the so-called wonder drug that has been recently touted as the cure for male impotence- medically termed "erectile dysfunction". Sildenafil is the generic name of this drug.

The prevalence of erectile dysfunction is about 10 per cent across all age ranges. Less than 5 per cent of men seek treatment, and before this drug the usual treatments included penile implants, drugs given by injection and vacuum devices. The relatively increased acceptability of an oral drug may stimulate demand for treatment from more patients.

Now, there are indications that it would soon be available in the Sri Lankan market though the cost may be prohibitive. At the same time there have been disturbing reports of side effects and even deaths following its use.

Here then are the facts about this drug:Sildenafil should be used only as a treatment for male erectile dysfunction.

Tablets are available in 25 mg, 50 mg or 100 mg preparations. It acts by promoting the relaxation of a type of cells in the penis which cause blood to accumulate in the organ.

It is well absorbed and reaches its maximum blood level an hour after taking the tablet when the maximum effect is seen. Food delays absorption of the drug.

There should be no accumulation of the drug if it is taken once daily. There is some evidence of its efficacy in patients with impotence secondary to diabetes and traumatic spinal injury.

Sildenafil should not be used in a variety of conditions. Recent stroke or heart attacks preclude sildenafil use. It should also not be used if "nitrates"-another group of drugs- usually given for heart ailments are being used by the patient.

Other conditions where the drug may not be used include visual disturbances, hypotension( a lowering of blood pressure), heart or liver disease, sickle cell anaemia, leukaemia, multiple myeloma, bleeding disorders, active peptic ulceration, Peyronie's disease or any other deformation of the penis. It should not be used along with other treatments for erectile dysfunction.

Side effects of the drug include headache, dyspepsia, flushing, diarrhoea, muscle pain and altered vision. About five per cent of patients discontinue the drug because of side effects.

Because of the potentially dangerous side-effects, it should be used only on prescription by a doctor- even though the drug is said to be available on the internet and in the open market.

Stomach upset

By Chris Fernando

Q: I am a 63-year-old retired public servant, male. I take a 50 mg Atenolol tablet daily in the morning to control blood pressure. For about five years now, I have been suffering from an unsettled stomach, with various sounds and movements in the lower abdomen. After breakfast I feel as if I am suffering from Irritable Bowel Syndrome with insufficient bowel function. The evenings are worse, as I suffer from abdominal discomfort and wind. I find it difficult to pass stools although I am not constipated. There is no bleeding. I don't suffer from pain, only discomfort in the stomach, which is often puffed up.

Whenever the problems aggravate, I take western and ayurvedic treatment. Digene helps settle the discomfort temporarily while Hetrazan tablets also help settle the stomach. Could you please recommend treatment?

Dr. Maiya says: From the description of your illness, I would say that your problem lies in the gastro-intestinal tract.

Upper abdominal discomfort is mainly caused by gastro-oesophageal reflex disease or a stomach ulcer. The presence of gall bladder stones can also precipitate the symptoms that you have described.

What I would recommend in your case is an X-ray of the abdomen together with an ultra-sound scan, which would help exclude pathology of the gall bladder, liver and pancreas. This would also reveal the presence of any intra-abdominal solid or cystic masses.

A liver and renal function blood test should also be done followed by an upper gastro-intestinal endoscopy (commonly known as gastroscopy). This test will show up any pathology in the swallowing passage, stomach and stomach outlet. A gastroscopy is performed under sedation with no discomfort to the patient. The gastroscope is a very flexible fibre-optic tube, which is slightly thicker than the size of an adult male's little finger.

Since you have difficulty with your motions and suffer from rumbling noises in the stomach, a colonoscopy should also be done to exclude any large bowel pathology because you are in an age group where this disease can occur. A colonoscopy is a procedure similar to the gastroscopy. This test is performed under sedation by using the colonoscope, which is slightly thicker and much longer than the gastroscope. Through this, the entire large bowel can be viewed. This test is usually performed after giving the patient laxatives to clear the large bowel of faecal matter.

You have also mentioned that you were suffering from Irritable Bowel Syndrome. An Irritable Bowel Syndrome is a functional derangement of the gastro-intestinal tract, which produces non-rhythmic contractions. These can affect any part of the gastro-intestinal tract from the swallowing passage (oesophagus) and any part of the bowel, down to the rectum.

However, the causes and pathogenesis of Irritable Bowel Syndrome still remain unclear although it has been found that it does not occur due to any organic pathology. Cervical and laboratory evidence indicates that this is a disorder of bowel mobility. Constipation and abdominal cramps are prominent complaints of many patients suffering from Irritable Bowel Syndrome.

On the other hand, it is possible that patients suffering from Irritable Bowel Syndrome will also complain of diarrhoea as a result of increased mobility of the bowel.

Characteristic features suggestive of Irritable Bowel Syndrome are constipation or diarrhoea or both, crampy abdominal pains, mucus stool symptoms, all of these getting worse under stress. The body weight will be stable or increasing, symptoms will be of long-standing duration and patients will appear healthy.

Irritable Bowel Syndrome is of course, diagnosed after all the investigations prove negative. It is diagnosed by exclusion.

Therefore, it is dangerous to assume any gastro-intestinal symptoms similar to yours as being due to irritable bowels before doing proper investigations via the endoscope and colonoscope to exclude or detect pathology.

You have not mentioned whether or not you have undergone any sort of abdominal surgery. Sometimes, when patients undergo surgery or a laparotomy (abdominal surgery), intestines can become adherent or get stuck to the scar from inside and this can cause recurrent abdominal pains.

If the above investigations don't help in diagnosing your illness, further tests such as the barium meal, which outlines the entire small bowel, can be done or a CT Scan of the abdomen.

Bed wetting: dos and don'ts

Bedwetting up to the age of five is considered normal, and treatment is not usually given. You may, however, find the following measures helpful if an older child wets the bed at night.

Ensure that the child passes urine just before he goes to bed.

Try not to get angry or irritated with your child. Instead, when the child wets the bed, get him to clean up. Don't do it for him.

Protect the mattress with a plastic cover.

Check whether your child is afraid to get up at night - would a night light in the room help?

Setting an alarm to wake up at a particular time to pass urine may help the child gain control.

Restrict fluids during the latter part of the day. However in the mornings, it is better for the child to drink around six or seven cups of fluid so that his bladder learns to hold a larger capacity.

Avoid giving fizzy drinks, citrus juices and those with caffeine such as tea, cola and chocolate before your child goes to bed as these can stimulate the kidneys to produce more fluid.

Being constipated also irritates the bladder. Try to ensure good bowel movement by giving plenty of fruits and green leafy vegetables.

When the child has a dry day, praise him and reward him with something he likes. That can go a long way in reinforcing his bladder control.

Never compare the child with a younger or older child who has bladder control.

The comparison will do more harm than good.

And, if the child continues to wet the bed despite all these measures and if he is more than five years old, it is best to see a doctor.

Exercise

A short cut to good health

Exercise has always been fashionable among professionals as a pathway to good health but others dismiss this as only a fad and nothing more. The truth is that exercise is indeed an easy means towards better health- though it does not necessarily mean dressing up and jogging at a public place.

Healthy exercise can be easily incorporated into your daily routine. But for that, people should realise why exercise is healthy and how it can become a pleasure instead of a painful task.

Consider these facts:

About one in five men will die from either a heart attack or stroke.

Exercise can reduce the risk of heart disease by a half.

The majority of men do not take enough exercise to benefit their health.

Exercise might prevent the development of 1 in 4 cases of diabetes mellitus.

How much exercise is 'enough'?

Try jogging, cricket or football or some strenuous sport for 20 minutes, 3 times a week. If you prefer something gentler then why not opt for walking, swimming or cycling for 30 minutes, 5 times a week.

Try to incorporate exercise into your daily routine, take the stairs rather than the lift, walk short distances instead of taking the bus. The myths: "I've no time" - try walking instead of using the car for small journeys. "I'm not the sporty type" - You don't have to be, just try and be more active.

The painful truth about kidney stones

Kidney stones (or calculi) can form in any part of the urinary tract, from the kidneys to the ureters (the tubes leading out of the kidneys), to the bladder.

They are quite common - and 3 times more likely in men than women.

The problem often recurs - about two thirds of patients will develop another stone within 7 years. In most cases, there is no obvious cause, although dehydration, prolonged bed rest, and urinary tract infection may all play a part.

All stones are not equal- there are several different types. In the majority of cases, the stone is made of calcium oxalate. Oxalate is a product of metabolism naturally found in the urine, and a diet, which is rich in oxalic acid which is found in certain foods. Occasionally, calcium stones occur as a result of problems with the parathyroid gland, which controls calcium metabolism in the body.

In about 1 in 5 cases, stones are caused by chronic urinary tract infections.

The bacteria break down urea in the urine to form excessive ammonia and make the urine alkali. This leads to the formation of stones, which contain calcium, magnesium and ammonium phosphate. In severe cases, the stones fill the whole of the middle of the kidney, causing a large stone known as a stag-horn calculus because of its shape.

About 1 in 20 stones is a uric acid stone, often linked to gout, but also to some cancers, and to chronic dehydration. Very rarely, stones are the result of other metabolic disorders.

The symptoms of a kidney stone depend greatly on where the stone is:

-Small stones in the kidney itself may cause no symptoms, and go unnoticed. But once stones enter the ureter, they can cause extreme and sudden pain in the loin (or side of the back), which moves down towards the groin. This pain (known as renal colic), is very sharp, may come in waves, and may make you feel nauseous, and even vomit.

-You may notice blood in your urine.

-Once the stone reaches the bladder, the pain may disappear. But now, you may find that you have problems passing urine, with a slow stream and dribbling, as the stone can block the exit to the bladder. There is also an increased risk of urinary tract infection setting in.

Preventing the development of kidney stones is easier said than done but a few strategies are helpful.

They include:

-avoiding dehydration (high fluid intake of at least 2-3 litres a day can help keep the urinary tract flushed out)

- rapid treatment of urinary tract infections

-specific treatments for metabolic disorders and gout.

If a kidney stone is suspected because of the nature of your symptoms, medical advice must be sought promptly.

A renal colic will disappear within a few hours, but the stone remains and has the potential to cause irreversible damage to the kidneys.

A few tests, such as special X-rays, will confirm the diagnosis and if surgery is indicated now there are many ways of removing these stones. Those decisions are best taken in consultation with your doctor- but it is important to seek treatment early.

Medical diary

June 25 (Today) - "Endotherapy in the new millennium"- Therapeutic endoscopic, workshop with demonstrations of endoscopic procedures, at King's Court, Trans Asia Hotel from 8.30 a.m. to 5.00 p.m. (Inquiries- 077-314693)

July 8 - Workshop on laparoscopic surgery and endostapling techniques at the Medical Research Institute, Colombo from 9 a.m. to 5 p.m. (Inquiries from office of College of Surgeons of Sri Lanka; participation limited).

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