To Do or Not To Do

That's a 'big' question in millions of circumstances that one may come across in the field of medicine. (in many other fields too, but usually in medicine a life depends on this decision)

One of the issues I was thinking about lately, was that of the conditions in which a doctor is permitted to breach the doctor-patient trust.

Patients put a lot of trust in their doctors, and reveal everything to them. There is no information that a doctor cannot obtain from his/her patients. The patients reveal their inner-most secrets to their doctors, completely trusting the doctor, and expecting their secrets to be in the safest of hands. A doctor-patient relationship is actually built on complete trust and this is the key for diagnosis and treatment of the cases.

However, there are certain conditions in which the doctor is permitted to disregard this trust and do what the circumstance requires him to. For example, on diagnosing a patient with a highly infectious disease which is a possible threat to become an epidemic in the region, the doctor is required to report to appropriate authorities. The patient maybe isolated until complete treatment, or deported from the country (in certain specific countries). Or if the patient was diagnosed with a sexually transmitted disease, it becomes the duty of the doctor to inform the patient's partner (even if the patient does not wish this). In the Gulf countries, it is required by the doctor to report any sexually transmitted disease to the respective authorities, a certain list of infectious diseases and certain other conditions are to be reported.

Yet, during my clinical training hours so far I have witnessed several episodes where the doctors do not do this. Sometimes out of sympathy for the patient, and sometimes I see the doctor has no concern at all.

There have been several instances where the doctor is sympathetic towards the patient (perhaps a labourer who may get deported if reported).

The question is what do you do in these circumstances? What decision do you make? What conditions do you apply when making this decision? Should it be based on ethics? morale? or sympathy?

Hard choice to make in some cases!

Life Within Life

Now that I'm posted in the Obstetrics and Gynaecology department, I get to see a lot of pregnant women. Its amazing to watch the ultrasounds of the fetuses, watch their hearts beat, watch them sleeping or waving their hands, sucking their thumbs and so on. Its probably one of the most beautiful things ever, and one of the most beautiful feelings too. Its also lovely to see the smile on the mother's face on seeing her babies heart beat, and its little feet and hands. I wouldn't know, but it is amazing to think that you are actually carrying another life within yourself.

I'll rant about some pregnancy related stuff now. I think I'll start with calculating or estimating the age of the gestation (pregnancy).

Gestational age (GA) is basically calculated from the woman's first day of her last menstrual period (LMP). Basically, you know that your expected date of delivery (EDD) is 40 weeks from your LMP or an estimated 280 days or 10 lunar months. The traditional method of calculation is (LMP - 3months + 7days) and then adjust the year accordingly. Nowadays, there are ready-made charts available for easy use. However, this method of estimation is rarely accurate. (It is after-all an estimation.)

Another method is by clinical assessment of the size of the uterus, which is usually useful upto 28 to 30 weeks. You measure the fundal height using a tape measure. The uterus maynot be palpable until 12 weeks. And by 30 weeks (some books say 32 weeks, some say 34 weeks) the uterus reaches the maximum possible height it can attain.

Fetal movement is usual appreciated by the mother between 17-21 weeks (5th or 6th month). This is referred to as quickening (in medical terms).

The more accurate method of assessment is the ultrasonography.

During the first trimester (first 3 months), the fetal crown-rump length (CRL) is measured. Formula for calculating GA from CRL is kinda complicated (I dont know it by-heart :$). The ultrasound machines usually auto-calculate the GA for you (hehe). Anyway, this method is used until about 12 weeks. This can also help assess fetal growth and development.

During the second and third trimester, the best measurement is bi-parietal diameter (BPD). You can also use head circumference (HC) or femur length (FL). However, BPD is almost always routinely done and is also the easiest. Again the ultrasound machine auto-calculates the GA. BPD refers to the diameter of the head between the two parietals (kinda like saying from ear to ear).

Okay thats all for now.

Acne Vulgaris

A common disorder of the pilosebaceous unit affecting millions of teenagers around the world.

There are three factors which play a role in the pathogenesis of acne:
a) Hyperproliferation and hyperkeratinization of epidermal cells lining the duct, which results in plugging of the duct and comedone formation.
b) Excess sebum production, which is usually regulated by androgens or other hormones such as Growth Hormone or Insulin-like Growth Factor.
c) Propionibacterium acnes, which causes inflammation at the site of infection is not always the causative agent, and not found in all acne lesions.
d) Inflammation, which may be due to the presence of P. Acnes bacteria as mentioned above or due to release of various cytokines from the comedone.

Medical care is aimed at attacking one of the above causative factors.

Topical retinoids may act as a comedolytic and as an anti-inflammatory agent.
Topical antibiotics and benzoyl peroxide are used to combat the P. Acnes bacteria in the lesions. They may also have mild anti-inflammatory action.
Systemic antibiotics like tetracylcine or minocycline, are sometimes used for the same purpose as the topical ones.
Antibiotics like, Trimethoprim and sulfamethoxazole are also often used.

In some severe cases, especially in those who have an underlying disorder (such as PolyCystic Ovarian Disease) may require hormone therapy. Oral contraceptive pills have been found to be useful in this regard. However, the side effects should be weighed against the benefits and should be used with care.

Isotretinoin is to be used as a final alternative. It affects acne development at all 4 stages mentioned above. However, it should be used with great care due its teratogenic effect (avoid pregnancy during its use). it is also compulsory to do regular blood profile analysis including cholesterol and triglyceride, hepatic transaminases and a CBC count.

There are studies which are still to be conducted and under-progress to establish a solid relation between diet and acne. It is highly likely that they are linked. Myself along with 3 other colleagues of mine conducted a study on the relation between acne and diet among university students in the United Arab Emirates. We found a significant relation between the severity of acne and the glycemic index of their diet. The higher the glycemic index of their regular diet, the more severe the acne they suffered from. Studies have shown that high glycemic index food increases the level of circulating Insulin-like Growth Factor. However, there were several limitations and un-avoidable confounding variables in the study due to the lack of time and resources. Further studies need to be done to re-establish this point.

Also, exposure to sunlight has proved to increase acne lesions in various subjects. This may be due to the inflammatory reaction, increased sebum production or hyperproliferation of the epithelial cells.

Another factor may be the use of certain creams and cosmetics. A possible explanation is an allergic reaction due to the irritation caused by the chemical ingredients in the creams and cosmetics. The resultant inflammation again results in comedones and other acne lesions.

Hence, non-medical treatment such as abstinance from food items which may trigger acne flares and avoiding exposure to sun-light is as important or perhaps even more important than the medical treatment. Identify the trigger factor and avoid them. Prevention is always better than cure.

Avian/Bird Flu

Since I know some stuff about it because I had to prepare a poster for the first annual medical students conference, a few weeks back, along with wahdamuslima and two other colleagues of mine.

Avian flu is very similar to the common cold (flu) that every human being catches at least once in his lifetime. The causative organism is obviously different. Human flu is caused by Human Influenza Virus. Avian flu is caused by a mutant form of a virus which was initially capable only of infecting birds. This virus is labelled H5N1 (because of its surface heamagglutinin-H and neuraminidase-N molecules).

You see, the reason why this virus is a threat, is because of its ability to mutate. This is because of its lack of enzymes responsible for proof-reading of the new genetic material synthesized. Hence, everytime the virus divides, there is a new error in the genes which provides its progeny with new capabilities. This is kinda how it obtained the ability to infect humans. There was also another theory I read about where two different subtypes of avian flu viruses amongst birds mixed their genetic material when they infect the same organism, giving rise to a new subtype.

Also, you should know why this avian flu is a threat to humans. So far, there is no officially reported case of avian flu being transmitted from human to human. Its always been from birds to humans. This way we can either just kill all the suspected birds (ha! easier said than done!!) or just use protective measures and keep away from birds maybe? But nothing can be done if it starts transmitting from human to human. It would be absurd to go around killing people who are suspected cases (not to mention charges of man-slaughter). Here I would like to put forth another theory suggesting the possibility of genetic alteration that may occur in a cell infected with both avian flu virus and human influenza at the same time. The avian flu virus has a potential of acquiring the ability of human to human transmission from the human influenza virus.

Another thing to worry about would be the difficulty that one would face, in coming up with a vaccine or even a drug against this virus. Everytime you create one that might attack the genetic core of the virus, it will simply mutate again and all your hardwork gone down the drain. So far, the drugs especially Tamiflu is designed to target the surface molecules. Neuraminidase is necessary to break through the cell membrane of an already infected cell and attack new cells. Tamiflu blocks the neuraminidase which prevents it from escaping a cell once it has replicated.

What you need to know now, is to look for signs of bird flu and be aware so that you can seek immediate medical care. Most often than not, the symptoms are pretty much the same as you would experience when you're suffering from human flu. Also, remember to take special precautions when handling bird meat.

Most importantly remember that the virus is killed at high temperatures (upto 56 degrees celcius). Make sure you cook the meat well and thoroughly. The same applies for eggs as well. Have it well cooked, and not runny.

Also, make sure you know of the areas affected (especially if you travel often or decide to travel), and be aware of whether the area you live in is affected or not.

Just an Intro..

So I finally decided to make a second blog where I can put all medical related stuff. At first, I thought I should'nt since I can't even keep up with just one blog. But then, later I thought of how this could actually help me study better and research more often as well. I've been slacking off on my studies lately, due to certain extra-academic stuff I've been keeping myself busy with. So let's see how well or even how far this goes. InshaAllah I'll try to keep up.