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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
Ma y 2 0 1 4
Vol 4 - Issue No. 42 - May 2014
Editorial Team
Honorary Editor:
Dr. Faysal S. Zeerah
Dr. Dilip Malhotra
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.
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Email: [email protected]
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Thank You.
3 Events and Health Promotions
4 Allergies
5 Halitosis (Bad Breath)
6 Carotid Artery Disease
Steel Crowns in Paediatric
7 Stainless
Mumps in Children
Spinal Cord Injury
Diabetic Retinopathy
Dental Braces for Adults
Acute Prostatitis
The Way Children Walk
Disease Modifying Anti-Rheumatic
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.
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International Hospital of Bahrain W. L.L.
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Email: [email protected]
Dr. Farooq Ahmed
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
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
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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.
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
(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.
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.
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.
• 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
• 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.
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.
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Carotid Artery
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.
• Carotid Duplex Ultrasound – This test uses
sound waves to diagnose stenosis of the
• 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.
The aim of treatment is to prevent stroke. This
Dr. Amany Serag
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
• 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
• Surgery – For removal of the plaque from the
carotid arteries. This is called “carotid endarterectomy.” This treatment is most appropriate for
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Stainless Steel Crowns In
Paediatric Dentistry
Dr. Bijosh Jose
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
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
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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
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
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.
Mumps in
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
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.
the most common complication of
mumps infection in the adult male. Symptoms are
characterized by the abrupt onset of fever from 39
to 41ВєC and severe testicular pain, accompanied by
swelling and erythema of the scrotum.
Oophoritis: occurs in seven percent of post-pubertal girls.
Dr. Germine Soliman
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 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
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-BarrГ© syndrome, transverse
myelitis, and facial palsy .
Less frequent complication linked to mumps infection include thyroiditis, myocardial involvement,
pancreatitis, interstitial nephritis and arthritis .
When the patient has parotitis, the diagnosis of
mumps is based upon the characteristic clinical
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Dr. Khaled Galil
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
• 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.
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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
• 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
• 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
• "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.
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Dr. Yousry Hannah
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.
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.
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.
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.
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The Way
Children Walk
Dr. Khaled Zaki
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.
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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
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
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.
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.
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Disease Modifying
Anti-Rheumatic Drugs
Dr. Peter Farag
(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,
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
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
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.
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Spinal Cord Injury
Dr. Samy Gouda
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
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.
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Fight Stress with
Healthy Habits
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.
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