Travel Associated Infections & Diseases


Depending on the travel destination, travellers may be exposed to a number of infectious diseases; exposure depends on the presence of infectious agents in the area to be visited. The risk of becoming infected will vary according to the purpose of the trip and the itinerary within the area, the standards of accommodation, hygiene and sanitation, as well as the behaviour of the traveller. In some instances, disease can be prevented by vaccination, but there are some infectious diseases, including some of the most important and most dangerous, for which no vaccines exist.

As many of such diseases are infections, general precautions can greatly reduce the risk of exposure to infectious agents and should always be taken for visits to any destination where there is a significant risk of exposure, regardless of whether any vaccinations or medication have been administered.

Modes of transmission and general precautions

The modes of transmission for different infectious diseases are diverse: 

  • Foodborne and waterborne diseases transmitted by consumption of contaminated food and drink. 
  • Vector-borne diseases transmitted by insects such as mosquitoes and other vectors such as ticks.
  • Diseases transmitted to humans by animals (zoonoses), more particularly through animal bites or contact with animals, contaminated body fluids or faeces, or by consumption of foods of animal origin, particularly meat and milk products. 
  • Sexually transmitted diseases passed from person to person through unsafe sexual practices.
  • Bloodborne diseases  transmitted by direct contact with infected blood or other body fluids
  • Airborne diseases involving droplets and droplets nuclei. Droplet nuclei <5 µm in size are disseminated in the air and breathed in. These droplet nuclei can remain suspended in the air for some time. Droplet nuclei are the residuals of evaporated droplets. Droplet transmission occurs when larger particles (>5 µm) contact the mucous membranes of the nose and mouth or conjunctivae of a susceptible individual. Droplets are usually generated by the infected individual during coughing, sneezing or talking. 
  • Diseases transmitted via soil include those caused by dormant forms (spores) of infectious agents, which can cause infection by contact with broken skin (minor cuts, scratches, etc). 

General precautions to prevent infections are outlined in the Chapter 5 of the international travel and health situation publication

Non vaccine-preventable diseases

The main infectious diseases to which travellers may be exposed, and precautions for each, are detailed in the Chapter 5 of the International travel and health situation publication. The most common infectious illness to affect travellers, namely travellers’ diarrhoea, is covered in Chapter 3 of the International travel and health situation publication (WHO). Because travellers’ diarrhoea can be caused by many different foodborne and waterborne infectious agents, for which treatment and precautions are essentially the same, the illness is not included with the specific infectious diseases.

Information on malaria, one of the most important infectious disease threats for travellers, is provided separately (WHO).

The infectious diseases listed below have been selected on the basis of the following criteria:

  • Diseases that have a sufficiently high global or regional prevalence to constitute a significant risk for travellers;
  • Diseases that are severe and life-threatening, even though the risk of exposure may be low for most travellers;
  • Diseases for which the perceived risk may be much greater than the real risk, and which may therefore cause anxiety to travellers;
  • Diseases that involve a public health risk due to transmission of infection to others by the infected traveller.
  • Amoebiasis
  • Angiostrongyliasis
  • Anthrax
  • Brucellosis
  • Chikungunya
  • Coccidioidomycosis
  • Dengue
  • Giardiasis
  • Haemorrhagic fevers
  • Hantavirus diseases
  • Hepatitis C
  • Hepatitis E
  • Histoplasmosis
  • HIV/AIDS and other sexually transmitted infections
  • Legionellosis
  • Leishmaniasis (cutaneous, mucosal and visceral forms)
  • Leptospirosis (including Weil disease)
  • Listeriosis
  • Lyme Borreliosis (Lyme disease)
  • Lymphatic filariasis
  • Malaria
  • Onchocerciasis
  • Plague
  • SARS (Severe Acute Respiratory Syndrome)
  • Schistosomiasis (Bilharziasis)
  • Trypanosomiasis
  • Typhus fever (Epidemic louse-borne typhus)
  • Zoonotic influenza

Some of the diseases included in this chapter, such as brucellosis, HIV/AIDS, leishmaniasis and TB, have prolonged and variable incubation periods. Clinical manifestations of these diseases may appear long after the return from travel, so that the link with the travel destination where the infection was acquired may not be readily apparent.

Special feature

Vaccine-preventable diseases

Vaccine-preventable diseases
  • Cholera
  • Hepatitis A
  • Hepatitis E
  • Japanese encephalitis
  • Meningococcal disease
  • Rabies
  • Tick-borne encephalitis
  • Typhoid fever
  • Yellow fever

Information about available vaccines and indications for their use by travellers is provided in the pdf entitled vaccine-preventable diseases and vaccines beside. Advice concerning the diseases for which vaccination is routinely administered in childhood, i.e. diphtheria, measles, mumps and rubella, pertussis, poliomyelitis and tetanus, and the use of the corresponding vaccines later in life and for travel, is also given in the section Vaccines.

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Malta Fever- Brucellosis- Mediterranean fever


           Brucellosis is a common zoonotic infection caused by bacterial genus Brucella. Brucellosis is an old disease known by various names including undulant fever or Mediterranean fever. This is one of the infectious diseases transmissible between animals and humans.

Global distribution of Brucellosis-

      This infection is more common in Mediterranean areas, the south and the center of America, Africa, Asia, Arab peninsula, Indian subcontinent and the Middle East. The maximum incidence in the world had been reported in Syria. 

Other names:

Brucellosis, undulant fever, Mediterranean fever, Cyprus fever, and goat fever.​​​

Summary:

  • ‘Malta fever’ is a bacterial disease caused by various brucella species, which mainly infect cattle, swine, goats, sheep and dogs.
  • Malta fever is transmitted to humans through direct and indirect contact with infected animals.
  • Infection is most likely caused by ingesting unpasteurized milk or cheese from infected goats or sheep.
  • It causes flu-like symptoms, including fever and lethargy.
  • There is no human vaccine to prevent Malta fever, but it is important to take precautions to avoid it.

Overview:

Malta fever is a bacterial disease caused by various brucella species. Infection is transmitted to humans through direct and indirect contact with infected animals. It mostly affects individuals who work in the livestock sector. The consumption of raw milk and cheese made from raw milk (fresh cheese) is the major source of infection in man; however, human-to-human transmission is very rare. On the other hand, Malta fever remains a problem globally, because it is the most common bacterial infection spread from animals to humans around the world, as animals may be carrying the bacteria without showing any symptoms of illness.

Types of Brucella bacteria:

Types of brucella bacteria:

There are 8 known species of the brucella bacteria, but only four of them cause brucellosis in humans:

  • Maltese Brucellosis (B. melitensis): This type is the most common and most severe, and is found in lambs.
  • Pig Brucellosis (B. suis): This type infects individuals who come in contact with animals. It has a severe impact on humans.
  • Brucella abortus (B. abortus): It infects cows and is moderately severe.
  • Canine Brucellosis (B. canis): It infects individuals who come in contact with dogs and is moderately severe.

Other animals are also considered a primary source of the Brucella bacteria, including wild animals.

Cause:

Brucellosis is the result of being infected with the brucella bacteria.

Transmission:

  • Humans contract brucellosis by consuming unpasteurized dairy products and undercooked or raw meat of infected animals.
  • Direct contact with an infected animal or its bodily discharge (such as tissues, blood, urine, vaginal discharge, aborted fetuses, and placentas), via cracked skin, can also occur.
  • The disease can also be transmitted to humans through inhaling airborne agents in barns, stables, and sometimes laboratory and slaughterhouse.

Rare Means of Transmission:

  • From mother to fetus through the placenta
  • Sexual contact
  • Blood transfusion or marrow transplant from a person infected with Brucella
  • Few cases result from accidental pollination of an animal with brucellosis.

Incubation Period:

Symptoms usually appear within 5 to 60 days, and sometimes they takes several months to appear.

Who is at risk?

  • Vets
  • Livestock farmers
  • Slaughterhouse workers
  • Hunters
  • Microbiologists
  • Medical lab workers

Symptoms:

Malta fever can cause several symptoms. Some of them last for a long period of time. Initial symptoms include:

  • Fever
  • Sweating
  • Chills
  • Loss of appetite
  • Headache
  • Muscle, joint, and back pain
  • Fatigue and lethargy

When to see a doctor?

When a rapid rise in temperature, muscle pain or unusual weakness and persistent fever occurs. It is also crucial to see your doctor if you are among the groups at a higher risk of contracting the disease.

Complications:

  • Endocarditis (an infection of the endocardium, which is the inner lining of the heart or valves)
  • Arthritis
  • Orchitis (inflammation of the testicles)
  • Spleen or liver inflammation
  • Central nervous system inflammation.

Diagnosis:

  • Clinical examination
  • Laboratory tests: They involve searching for the bacteria in samples of blood, bone marrow, or other body fluids.

Treatment:

Treatment aims to relieve symptoms and prevent complications. It depends on the timing and severity of the disease. The disease may take a few weeks to several months to be cured. Patients take antibiotics for at least six weeks.

Prevention:

There is no human vaccine that can prevent Malta fever, so it is important to take precautions to prevent it with the following steps:

  • Make sure to cook meat well at a temperature of 63-74°C.
  • Do not drink or eat unpasteurized dairy products, including milk and cheese.
  • Take safety precautions at workplaces (e.g. during handling samples in laboratories).
  • Wash your hands before and after handling animals.
  • Wear rubber gloves and protective clothing and glasses if you work in a field where you come in contact with animals.
  • Ensure that wounds are covered with a bandage.

FAQs:

  • How long do brucella bacteria live outside the body?
    • Brucella bacteria are resistant to natural conditions, and they can survive for several hours up to over 60 days if the surrounding environment is moist.
  • How long should meat be cooked?
    • Meat and liver should be well cooked at 63°C  for half an hour.

What is the risk to pregnant women?

Women who are pregnant and have been exposed to Brucella should consult with their obstetricians/healthcare provider for evaluation. Prompt diagnosis and treatment of brucellosis in pregnant women can prevent complications including miscarriage.

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Anne Heche’s (Hollywood Actress) Accident-Brain Death & Organ Donation


  Brain dead patients are potential organ donors. 

Anne Heche, 53, had spent several days in a coma at the Grossman Burn Center at West Hills (California) Hospital and Medical Center after her Mini Cooper ran off the road Aug. 5 and smashed  into a two-story home.

      On Friday-  Anne Heche  (Hollywood actress ) had been declared brain dead, although she remained on life support for organ donation, a rep for the actress told  The Hollywood Reporter  on Friday. According to the actress’ publicist Holly Baird, Heche is “legally dead according to California law.” However, her heart is still beating and she has not been taken off of life support so that “OneLegacy can see if she is a match for organ donation.”

The actress’ team had previously shared an update on her health Thursday, stating that she suffered a severe anoxic brain injury and wasn’t expected to survive following an Aug. 5  car crash.

According to Baird, the star had been hospitalized in a coma and in critical condition since the accident. The actress crashed her car into a two-story home in L.A.’s Mar Vista neighborhood, sparking a fire, according to a Los Angeles Fire Department report.

In the statement Thursday from Heche’s rep, it “has long been her choice to donate her organs” and she was being kept on life support to determine whether her organs were viable.

 

National Organ Transplantation Programme (India)

Background

The shortage of organs is virtually a universal problem but Asia lags behind much of the rest of the world. India lags far behind other countries even in Asia.  It is not that there aren’t enough organs to transplant. Nearly every person who dies naturally, or in an accident, is a potential donor. Even then, innumerable patients cannot find a donor.

Situation of shortage of organs in India

There is a wide gap between patients who need transplants and the organs that are available in India. An estimated around 1.8 lakh persons suffer from renal failure every year, however the number of renal transplants done is around 6000 only. An estimated 2 lac patients die of liver failure or liver cancer annually in India, about 10-15% of which can be saved with a timely liver transplant. Hence about 25-30 thousand liver transplants are needed annually in India but only about one thousand five hundred are being performed. Similarly about 50000 persons suffer from Heart failures annually but only about 10 to 15 heart transplants are performed every year in India.  In case of Cornea, about 25000 transplants are done every year against a requirement of 1 lakh.

The legal Framework in India

Transplantation of Human Organs Act (THOA) 1994 was enacted to provide a system of removal, storage and transplantation of human organs for therapeutic purposes and for the prevention of commercial dealings in human organs. THOA is now adopted by all States except Andhra and J&K, who have their own similar laws. Under THOA, source of the organ may be:

  • Near Relative donor (mother, father, son, daughter, brother, sister, spouse)
  • Other than near relative donor: Such a donor can donate only out of affection and attachment or for any other special reason and that too with the approval of the authorisation committee.
  • Deceased donor, especially after Brain stem death e.g. a victim of road traffic accident etc. where the brain stem is dead and person cannot breathe on his own but can be maintained through ventilator, oxygen, fluids etc. to keep the heart and other organs working and functional. Other type of deceased donor could be donor after cardiac death.

Brain Stem death is recognized as a legal death in India under the Transplantation of Human Organs Act, like many other countries, which has revolutionized the concept of organ donation after death. After natural cardiac death only a few organs/tissues can be donated (like cornea, bone, skin and blood vessels) whereas after brain stem death almost 37 different organs and tissues can be donated including vital organs such as kidneys, heart, liver and lungs.

Despite a facilitatory law, organ donation from deceased persons continues to be very poor. In India there is a need to promote deceased organ donation as donation from living persons cannot take care of the organ requirement of the country. Also there is risk to the living donor and proper follow up of donor is also required. There is also an element of commercial transaction associated with living organ donation, which is violation of Law. In such a situation of organ shortage, rich can exploit the poor by indulging in organ trading.

Government of India initiated the process of amending and reforming the THOA 1994 and consequently, the Transplantation of Human Organs (Amendment) Act 2011 was enactedSome of the important amendments under the (Amendment) Act 2011 are as under:-

  1. Tissues have been included along with the Organs.
  2. ‘Near relative’ definition has been expanded to include grandchildren, grandparents.
  3. Provision of ‘Retrieval Centres’ and their registration for retrieval of organs from deceased donors. Tissue Banks shall also be registered.
  4. Provision of Swap Donation included.
  5. There is provision of mandatory inquiry from the attendants of potential donors admitted in ICU and informing them about the option to donate – if they consent to donate, inform retrieval centre.
  6. Provision of Mandatory ‘Transplant Coordinator’ in all hospitals registered under the Act
  7. To protect vulnerable and poor there is provision of higher penalties has been made for trading in organs.
  8. Constitution of Brain death certification board has been simplified- wherever Neurophysician or Neurosurgeon is not available, then an anaesthetist or intensivist can be a member of board in his place, subject to the condition that he is not a member of the transplant team.
  9. National Human Organs and Tissues Removal and Storage Network and National Registry for Transplant are to be established.
  10. There is provision of Advisory committee to aid and advise Appropriate Authority.
  11. Enucleation of corneas has been permitted by a trained technician.
  12. Act has made provision of greater caution in case of minors and foreign nationals and prohibition of organ donation from mentally challenged persons

In pursuance to the amendment Act, Transplantation of Human Organs and Tissues Rules 2014 have been notified on 27-3-2014

Directorate General of Health Services, Government of India is implementing National Organ Transplant Programme for carrying out the activities as per amendment Act, training of manpower and promotion organ donation from deceased persons.

National Organ Transplant Programme with a budget of Rs. 149.5 Crore for 12th Five year Plan aims to improve access to the life transforming transplantation for needy citizens of our country by promoting deceased organ donation. 

Issues and Challenges

  • High Burden (Demand  Versus Supply gap)
  • Poor Infrastructure especially in Govt. sector hospitals
  • Lack of Awareness of concept of Brain Stem Death among stakeholders
  • Poor rate of Brain Stem Death Certification by Hospitals
  • Poor Awareness and attitude towards organ donation— Poor Deceased Organ donation rate
  • Lack of Organized systems for organ procurement from deceased donor
  • Maintenance of Standards in Transplantation, Retrieval and Tissue Banking
  • Prevention and Control of Organ trading
  • High Cost (especially for uninsured and poor patients)
  • Regulation of Non- Govt. Sector

Objectives of National Organ Transplant Programme:

  • To organize a system of organ and Tissue procurement & distribution for transplantation.
  • To promote deceased organ and Tissue donation.
  • To train required manpower.
  • To protect vulnerable poor from organ trafficking.
  • To monitor organ and tissue transplant services and bring about policy and programme corrections/ changes whenever needed.

NOTTO: National Organ and Tissue Transplant Organization

National Network division of NOTTO would function as apex centre for all India activities of coordination and networking for procurement and distribution of organs and tissues and registry of Organs and Tissues Donation and Transplantation in country. The following activities would be undertaken to facilitate Organ Transplantation in safest way in shortest possible time and to collect data and develop and publish National registry.

At National Level:

  1. Lay down policy guidelines and protocols for various functions.
  2. Network with similar regional and state level organizations.
  3. All registry data from States and regions would be compiled and published.
  4. Creating awareness, promotion of deceased organ donation and transplantation activities.
  5. Co-ordination from procurement of organs and tissues to transplantation when organ is allocated outside region.
  6. Dissemination of information to all concerned organizations, hospitals and individuals.
  7. Monitoring of transplantation activities in the regions and States and maintaining data-bank in this regard.
  8. To assist the states in data management, organ transplant surveillance & Organ transplant and Organ Donor registry.
  9. Consultancy support on the legal and non-legal aspects of donation and transplantation
  10. Coordinate and Organize trainings for various cadre of workers.

For Delhi and NCR

  1. Maintaining the waiting list of terminally ill patients requiring transplants
  2. Networking with transplant centres, retrieval centres and tissue Banks
  3. Co-ordination for all activities required for procurement of organs and tissues including medico legal aspects.
  4. NOTTO will assign the Retrieval Team for Organ retrieval and make Transport Arrangement for transporting the organs to the allocated locations.
  5. NOTTO will maintain the waitlist of patients. needing transplantation in terms of the following:-
  6. Hospital wise
  7. Organ wise
  8. Blood group wise
  9. Age of the patient
  10. Urgency ( on ventilator, can wait etc.)
  11. Seniority in the waitlist (First in First Out)
  12. Matching of recipients with donors.
  13. Allocation, transportation, storage and Distribution of organs and tissues within Delhi and National Capital Territory region.
  14. Post-transplant patients & living donor follow-up for assessment of graft rejection, survival rates etc.
  15. Awareness, Advocacy and training workshops and other activities for promotion of organ donation
  16. ROTTO: Regional Organ and Tissue Transplant Organization
Name of ROTTOStates covered 
Seth GS medical college and KEM Hospital, Mumbai (Maharashtra)Maharashtra, Gujarat, Goa, UTs of DNH, Daman, Diu, M.P., Chhattisgarh
Govt. Multispecialty Hospital, Omnadurar, Chennai (Tamil Nadu)TN, Kerala, Telangana, Seem Andhra, Karnataka, Pondicherry, A & N Islands, Lakshadweep
Institute of PG Medical Education and Research, Kolkata (West Bengal)West Bengal, Jharkhand,Sikkim, Bihar and Orissa
PGIMER Chandigarh(UT of Chandigarh)Punjab, Haryana, HP, J &K , Chandigarh , Rajasthan, Uttar Pradesh and Uttarakhand
Guwahati Medical College (Assam)Assam, Meghalaya, Arunachal Pradesh, Manipur, Nagaland, Mizoram, Tripura.
  • SOTTO: State Organ and Tissue Transplant Organization

It is envisaged to make 5 SOTTOs in new AIIMS like institutions.

  • Govt. supported Online system of Networking

A website by the name www.notto.nic.in has been hosted where information with regards to the organ transplantation can be obtained. An online system through website is being developed for establishing network for Removal and Storage of Organs and Tissues from deceased donors and their allocation and distribution in a transparent manner. A computerized system of State/Regional and National Registry of donors and recipients is also going to be put in place.

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Sciatica: Pain Lower back radiating to Leg


Sciatica

Sciatica pain is caused by an irritation, inflammation, pinching or compression of a nerve in the lower back. The most common cause is a herniated or slipped disk that causes pressure on the nerve root. Most people with sciatica get better on their own with time and self-care treatments.

  • Symptoms and Causes 
  • Diagnosis and Tests
  • Management and Treatment 
  • Prevention 
  • Outlook / Prognosis    —-Living With

OVERVIEW– clevelandclinic

True sciatica is an injury or irritation to the sciatic nerve, which starts in your buttock/gluteal area.

What is sciatica?

Sciatica is nerve pain from an injury or irritation to the sciatic nerve, which originates in your buttock/gluteal area. The sciatic nerve is the longest and thickest (almost finger-width) nerve in the body. It’s actually made up of five nerve roots: two from the lower back region called the lumbar spine and three from the final section of the spine called the sacrum. The five nerve roots come together to form a right and left sciatic nerve. On each side of your body, one sciatic nerve runs through your hips, buttocks and down a leg, ending just below the knee. The sciatic nerve then branches into other nerves, which continue down your leg and into your foot and toes.

True injury to the sciatic nerve “sciatica” is actually rare, but the term “sciatica” is commonly used to describe any pain that originates in the lower back and radiates down the leg. What this pain shares in common is an injury to a nerve — an irritation, inflammation, pinching or compression of a nerve in your lower back.

If you have “sciatica,” you experience mild to severe pain anywhere along the path of the sciatic nerve – that is, anywhere from the lower back, through the hips, buttocks and/or down your legs. It can also cause muscle weakness in your leg and foot, numbness in your leg, and an unpleasant tingling pins-and-needles sensation in your leg, foot and toes.

What does sciatica pain feel like?

People describe sciatica pain in different ways, depending on its cause. Some people describe the pain as sharp, shooting, or jolts of pain. Others describe this pain as “burning,” “electric” or “stabbing.”

The pain may be constant or may come and go. Also, the pain is usually more severe in your leg compared to your lower back. The pain may feel worse if you sit or stand for long periods of time, when you stand up and when your twist your upper body. A forced and sudden body movement, like a cough or sneeze, can also make the pain worse.

Can sciatica occur down both legs?

Sciatica usually affects only one leg at a time. However, it’s possible for sciatica to occur in both legs. It’s simply a matter of where the nerve is being pinched along the spinal column.

Does sciatica occur suddenly or does it take time to develop?

Sciatica can come on suddenly or gradually. It depends on the cause. A disk herniation can cause sudden pain. Arthritis in the spine develops slowly over time.

How common is sciatica?

Sciatica is a very common complaint. About 40% of people in the U.S. experience sciatica sometime during their life. Back pain is the third most common reason people visit their healthcare provider.

What are the risk factors for sciatica?

You are at greater risk of sciatica if you:

  • Have an injury/previous injury: An injury to your lower back or spine puts you at greater risk for sciatica.
  • Live life: With normal aging comes a natural wearing down of bone tissue and disks in your spine. Normal aging can put your nerves at risk of being injured or pinched by the changes and shifts in bone, disks and ligaments.
  • Are overweight: Your spine is like a vertical crane. Your muscles are the counterweights. The weight you carry in the front of your body is what your spine (crane) has to lift. The more weight you have, the more your back muscles (counterweights) have to work. This can lead to back strains, pains and other back issues.
  • Lack a strong core: Your “core” are the muscles of your back and abdomen. The stronger your core, the more support you’ll have for your lower back. Unlike your chest area, where your rib cage provides support, the only support for your lower back is your muscles.
  • Have an active, physical job: Jobs that require heavy lifting may increase your risk of low back problems and use of your back, or jobs with prolonged sitting may increase your risk of low back problems.
  • Lack proper posture in the weight room: Even if you are physically fit and active, you can still be prone to sciatica if you don’t follow proper body form during weight lifting or other strength training exercises.
  • Have diabetes: Diabetes increases your chance of nerve damage, which increases your chance of sciatica.
  • Have osteoarthritis: Osteoarthritis can cause damage to your spine and put nerves at risk of injury.
  • Lead an inactive lifestyle: Sitting for long period of time and not exercising and keeping your muscles moving, flexible and toned can increase your risk of sciatica.
  • Smoke: The nicotine in tobacco can damage spinal tissue, weaken bones, and speed the wearing down of vertebral disks.

Is the weight of pregnancy the reason why so many pregnant women get sciatica?

It’s true that sciatica is common in pregnancy but increased weight is not the main reason why pregnant women get sciatica. A better explanation is that certain hormones of pregnancy cause a loosening of their ligaments. Ligaments hold the vertebrae together, protect the disks and keep the spine stable. Loosened ligaments can cause the spine to become unstable and might cause disks to slip, which leads to nerves being pinched and the development of sciatica. The baby’s weight and position can also add pressure to the nerve.

The good news is there are ways to ease sciatic pain during pregnancy, and the pain goes away after birth. Physical therapy and massage therapy, warm showers, heat, medications and other measures can help. If you are pregnant, be sure to follow good posture techniques during pregnancy to also ease your pain.

SYMPTOMS AND CAUSES

What causes sciatica?

Sciatica can be caused by several different medical conditions including:

  • A herniated or slipped disk that causes pressure on a nerve root. This is the most common cause of sciatica. Disks are the cushioning pads between each vertebrae of the spine. Pressure from vertebrae can cause the gel-like center of a disk to bulge (herniate) through a weakness in its outer wall. When a herniated disk happens to a vertebrae in your lower back, it can press on the sciatic nerve.
  • Degenerative disk disease is the natural wear down of the disks between vertebrae of the spine. The wearing down of the disks shortens their height and leads to the nerve passageways becoming narrower (spinal stenosis). Spinal stenosis can pinch the sciatic nerve roots as they leave the spine.
  • Spinal stenosis is the abnormal narrowing of the spinal canal. This narrowing reduces the available space for the spinal cord and nerves.
  • Spondylolisthesis is a slippage of one vertebra so that it is out of line with the one above it, narrowing the opening through which the nerve exits. The extended spinal bone can pinch the sciatic nerve.
  • Osteoarthritis. Bone spurs (jagged edges of bone) can form in aging spines and compress lower back nerves.
  • Trauma injury to the lumbar spine or sciatic nerve.
  • Tumors in the lumbar spinal canal that compress the sciatic nerve.
  • Piriformis syndrome is a condition that develops when the piriformis muscle, a small muscle that lies deep in the buttocks, becomes tight or spasms. This can put pressure on and irritate the sciatic nerve. Piriformis syndrome is an uncommon neuromuscular disorder.
  • Cauda equina syndrome is a rare but serious condition that affects the bundle of nerves at the end of the spinal cord called the cauda equina. This syndrome causes pain down the leg, numbness around the anus and loss of bowel and bladder control.

What are the symptoms of sciatica?

The symptoms of sciatica include:

  • Moderate to severe pain in lower back, buttock and down your leg.
  • Numbness or weakness in your lower back, buttock, leg or feet.
  • Pain that worsens with movement; loss of movement.
  • “Pins and needles” feeling in your legs, toes or feet.
  • Loss of bowel and bladder control (due to cauda equina).

DIAGNOSIS AND TESTS

Straight leg raise test helps spot your point of pain. This test helps identify a disk problem.

How is sciatica diagnosed?

First, your healthcare provider will review your medical history. Next, they’ll ask about your symptoms.

During your physical exam, you will be asked to walk so your healthcare provider can see how your spine carries your weight. You may be asked to walk on your toes and heels to check the strength of your calf muscles. Your provider may also do a straight leg raise test. For this test, you’ll lie on your back with your legs straight. Your provider will slowly raise each leg and note the point at which your pain begins. This test helps pinpoint the affected nerves and determines if there is a problem with one of your disks. You will also be asked to do other stretches and motions to pinpoint pain and check muscle flexibility and strength.

Depending on what your healthcare provider discovers during your physical exam, imaging and other tests might be done. These may include:

  • Spinal X-rays to look for spinal fractures, disk problems, infections, tumors and bone spurs.
  • Magnetic resonance imaging (MRI) or computed tomography (CT) scans to see detailed images of bone and soft tissues of the back. An MRI can show pressure on a nerve, disk herniation and any arthritic condition that might be pressing on a nerve. MRIs are usually ordered to confirm the diagnosis of sciatica.
  • Nerve conduction velocity studies/electromyography to examine how well electrical impulses travel through the sciatic nerve and the response of muscles.
  • Myelogram to determine if a vertebrae or disk is causing the pain.

MANAGEMENT AND TREATMENT

How is sciatica treated?

The goal of treatment is to decrease your pain and increase your mobility. Depending on the cause, many cases of sciatica go away over time with some simple self-care treatments.

Self-care treatments include:

  • Appling ice and/or hot packs: First, use ice packs to reduce pain and swelling. Apply ice packs or bag of frozen vegetables wrapped in a towel to the affected area. Apply for 20 minutes, several times a day. Switch to a hot pack or a heating pad after the first several days. Apply for 20 minutes at a time. If you’re still in pain, switch between hot and cold packs – whichever best relieves your discomfort.
  • Taking over-the-counter medicines: Take medicines to reduce pain, inflammation and swelling. The many common over-the-counter medicines in this category, called non-steroidal anti-inflammatory drugs (NSAIDs), include aspirin, ibuprofen and naproxen. Be watchful if you choose to take aspirin. Aspirin can cause ulcers and bleeding in some people. If you’re unable to take NSAIDS, acetaminophen may be taken instead.
  • Performing gentle stretches: Learn proper stretches from an instructor with experience with low back pain. Work up to other general strengthening, core muscle strengthening and aerobic exercises.

How long should I try self-care treatments for my sciatica before seeing my healthcare professional?

Every person with sciatic pain is different. The type of pain can be different, the intensity of pain is different and the cause of the pain can be different. In some patients, a more aggressive treatment may be tried first. However, generally speaking, if a six-week trial of conservative, self-care treatments – like ice, heat, stretching, over-the-counter medicines – has not provided relief, it’s time to return to a healthcare professional and try other treatment options.

Other treatment options include:

  • Prescription medications: Your healthcare provider may prescribe muscle relaxants, such as cyclobenzaprine. to relieve the discomfort associated with muscle spasms. Other medications with pain-relieving action that may be tried include tricyclic antidepressants and anti-seizure medications. Depending on your level of pain, prescription pain medicines might be used early in your treatment plan.
  • Physical therapy: The goal of physical therapy is to find exercise movements that decrease sciatica by reducing pressure on the nerve. An exercise program should include stretching exercises to improve muscle flexibility and aerobic exercises (such as walking, swimming, water aerobics). Your healthcare provider can refer you to a physical therapist who’ll work with you to customize your own stretching and aerobic exercise program and recommend other exercises to strengthen the muscles of your back, abdomen and legs.
  • Spinal injectionsAn injection of a corticosteroid, an anti-inflammatory medicine, into the lower back might help reduce the pain and swelling around the affected nerve roots. Injections provide short-time (typically up to three months) pain relief and is given under local anesthesia  as an outpatient treatment. You may feel some pressure and burning or stinging sensation as the injection is being given. Ask your healthcare provider about how many injections you might be able to receive and the risks of injections.
  • Alternative therapies: Alternative therapies are increasingly popular and are used to treat and manage all kinds of pain. Alternative methods to improve sciatic pain include spine manipulation by a licensed chiropractor, yoga or acupuncture. Massage might help muscle spasms that often occur along with sciatica. Biofeedback is an option to help manage pain and relieve stress.

When is surgery considered?

Spinal surgery is usually not recommended unless you have not improved with other treatment methods such as stretching and medication, your pain is worsening, you have severe weakness in the muscles in your lower extremities or you have lost bladder or bowel control.

How soon surgery would be considered depends on the cause of your sciatica. Surgery is typically considered within a year of ongoing symptoms. Pain that is severe and unrelenting and is preventing you from standing or working and you’ve been admitted to a hospital would require more aggressive treatment and a shorter timeline to surgery. Loss of bladder or bowel control could require emergency surgery if determined to be cauda equine syndrome.

The goal of spinal surgery for sciatic pain is to remove the pressure on the nerves that are being pinched and to make sure the spine is stable.

Surgical options to relieve sciatica include:

Microdiscectomy: This is a minimally invasive procedure used to remove fragments of a herniated disk that are pressing on a nerve.

  • Laminectomy: In this procedure, the lamina (part of the vertebral bone; the roof of the spinal canal) that is causing pressure on the sciatic nerve is removed.

How long does it take to perform spine surgery and what’s the typical recovery time?

Discectomy and laminectomy generally take one to two hours to perform. Recovery time depends on your situation; your surgeon will tell you when you can get back to full activities. Generally the time needed to recover is six weeks to three months.

What are the risks of spinal surgery?

Though these procedures are considered very safe and effective, all surgeries have risks. Spinal surgery risks include:

  • Bleeding.
  • Infection.
  • Blood clots.
  • Nerve damage.
  • Spinal fluid leak.
  • Loss of bladder or bowel control.

What complications are associated with sciatica?

Most people recover fully from sciatica. However, chronic (ongoing and lasting) pain can be a complication of sciatica. If the pinched nerve is seriously injured, chronic muscle weakness, such as a “drop foot,” might occur, when numbness in the foot makes normal walking impossible. Sciatica can potentially cause permanent nerve damage, resulting in a loss of feeling in the affected legs. Call your provider right away if you lose feeling in your legs or feet, or have any concerns during your recovery time.

PREVENTION

Can sciatica be prevented?

Some sources of sciatica may not be preventable, such as degenerative disk disease, sciatica due to pregnancy or accidental falls. Although it might not be possible to prevent all cases of sciatica, taking the following steps can help protect your back and reduce your risk:

  • Maintain good postureFollowing good posture techniques while you’re sitting, standing, lifting objects and sleeping helps relieve pressure on your lower back. Pain can be an early warning sign that you are not properly aligned. If you start to feel sore or stiff, adjust your posture.
  • Don’t smoke: Nicotine reduces the blood supply to bones. It weakens the spine and the vertebral disks, which puts more stress on the spine and disks and causes back and spine problems.
  • Maintain a healthy weight: Extra weight and a poor diet are associated with inflammation and pain throughout your body. To lose weight or learn healthier eating habits, look into the Mediterranean diet. The closer you are to your ideal body weight the less strain you put on your spine.
  • Exercise regularly: Exercise includes stretching to keep your joints flexible and exercises to strengthen your core – the muscles of your lower back and abdomen. These muscles work to support your spine. Also, do not sit for long periods of time.
  • Choose physical activities least likely to hurt your back: Consider low-impact activities such as swimming, walking, yoga or tai chi.
  • Keep yourself safe from falls: Wear shoes that fit and keep stairs and walkways free of clutter to reduce your chance of a fall. Make sure rooms are well-lighted and there are grab bars in bathrooms and rails on stairways.

OUTLOOK / PROGNOSIS

What can I expect if I have been diagnosed with sciatica?

The good news about sciatic pain is that it usually goes away on its own with time and some self-care treatments. Most people (80% to 90%) with sciatica get better without surgery, and about half of these recover from an episode fully within six weeks.

Be sure to contact your healthcare provider if your sciatica pain is not improving and you have concerns that you aren’t recovering as quickly as hoped.

LIVING WITH

When should I contact my healthcare provider?

Get immediate medical attention if you experience:

  • Severe leg pain lasting more than a few hours that is unbearable.
  • Numbness or muscle weakness in the same leg.
  • Bowel or bladder control loss. This could be due to a condition called cauda equina syndrome, which affects bundles of nerves at the end of the spinal cord.
  • Sudden and severe pain from a traffic accident or some other trauma.

Even if your visit doesn’t turn out to be an emergency situation, it’s best to get it checked out.

Is the sciatic nerve the only source of “sciatica” pain?

No, the sciatic nerve is not the only source of what is generally called “sciatica” or sciatica pain. Sometimes the source of pain is higher up in the lumbar spine and causes pain in front of the thigh or in the hip area. This pain is still called sciatica.

How can I tell if pain in my hip is a hip issue or sciatica?

Hip problems, such as arthritis in the hip, usually cause groin pain, pain when you put weight on your leg, or when the leg is moved around.

If your pain starts in the back and moves or radiates towards the hip or down the leg and you have numbness, tingling or weakness in the leg, sciatica is the most likely cause.

Is radiculopathy the same as sciatica?

Radiculopathy is a broader term that describes the symptoms caused by a pinched nerve in the spinal column. Sciatica is a specific type, and the most common type, of radiculopathy.

Should I rest if I have sciatica?

Some rest and change in your activities and activity level may be needed. However, too much rest, bed rest, and physical inactivity can make your pain worse and slow the healing process. It’s important to maintain as much activity as possible to keep muscles flexible and strong.

Before beginning your own exercise program, see your healthcare provider or spine specialist first to get a proper diagnosis. This healthcare professional will refer you to the proper physical therapist or other trained exercise or body mechanics specialist to devise an exercise and muscle strengthening program that’s best for you.

Can sciatica cause my leg and/or ankle to swell?

Sciatica that is caused by a herniated disk, spinal stenosis, or bone spur that compresses the sciatic nerve can cause inflammation – or swelling – in the affected leg. Complications of piriformis syndrome can also cause swelling in the leg.

Are restless leg syndrome, multiple sclerosis, carpal tunnel syndrome, plantar fasciitis, shingles or bursitis related to sciatica?

While all these conditions affect either the spinal cord, nerves, muscles, ligaments or joints and all can cause pain, none are directly related to sciatica. The main causes of these conditions are different. Sciatica only involves the sciatic nerve. That being said, the most similar condition would be carpal tunnel syndrome, which also involves a compression of a nerve.

A final word about sciatica

Most cases of sciatica do not require surgery. Time and self-care treatment are usually all that’s needed. However, if simple self-care treatments do not relieve your pain, see your healthcare provider. Your healthcare provider can confirm the cause of your pain, suggest other treatment options and/or refer you to other spine health specialists if needed.

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ZERO Percentiles Requirement to be a Super Specialist Doctor- a Cruel Joke


          MUMBAI: With hundreds of medical super specialty course seats vacant, the authorities have removed the qualifying mark criterion for aspirants. So, rock-bottom scores or a zero percentile would be acceptable for a course at this level.

            Such decisions appear to be   cruel joke to the life of patients. A wise decision would be to review into reasons for vacant seats for example- policies, fee structure, facilities, demand for the course, and disillusionment of students by existing system or falling percentages to be a super-specialist doctor.  

          Imagine, an opportunity is available to a patient, to decide the doctor as based on his route or marks for entry into medical college. Whether patient will like to get treated by a doctor, who   secured 20% marks, 30 % marks or 60% marks or 80% marks for medical college.  Even   an illiterate person can answer that well. But strangely for selection of doctors, rules were framed so as to dilute the merit to the minimum possible. So that a candidate who scores 15-20 % marks also becomes eligible to become a doctor. That is now further diluted to nearly Zero percentile. Answer to that is simple.  To select and find only those students, who can pay millions to become doctors,  and hence marks and quality of doctors don’t matter?  

   If the society continues to accept such below par practices, it has to introspect, whether it actually deserves to get good doctors. Paying the irrational fee of medical colleges may be unwise idea for the candidates, especially those who are not from strong financial backgrounds. But at the same time unfortunately, it may be a compulsion and entrapment for students, who have entered the profession and there is no way  forward.  

So, rock-bottom scores or a zero percentile would be acceptable for a course at this level.

      Society needs to choose and nurture a force of doctors carefully with an aim to combat for safety of its own people. If society has failed to demand for a good doctors and robust system, it should not rue scarcity of good doctors. Merit based cheap good medical education system is the need of the society. This is in interest of society to nurture good doctors for its own safety.      The quality of doctors who survive and flourish in such system will be a natural consequence of how society chooses and nurtures the best for themselves.

    MUMBAI: With hundreds of medical super specialty course seats vacant, the authorities have removed the qualifying mark criterion for aspirants. So, rock-bottom scores or a zero percentile would be acceptable for a course at this level. “Seats have been going vacant every year. The government felt that as a one-time measure, in the larger context of things, we can even accept students with a zero percentile. This will not have any precedence. It is being taken up as a test case. After all, the entrance test was not conducted to eliminate students, but merely to grade them,” said a senior officer from the health ministry. With 748 super speciality seats unfilled after four rounds of admission this year, the Medical Counselling Committee (MCC) took the drastic step. As a one-time measure, any candidate who had taken the NEET super speciality 2021 exam can participate in the special mop-up admission round irrespective of his/her scores.

When admissions began this year, two rounds conducted by the MCC got a cold response. This led to a special mop-up round with the qualifying bar lowered by 15%. Yet, there weren’t many takers. Now the second mop-up round is open to all aspirants. India has about 4,500 super specialty medical seats. There is more vacancy in the surgical branches than the clinical ones. “Candidates have realised that having a broad speciality gives them a good career and money. Hence, many do not want to spend more time in pursuing a super specialty course,” said Dr Pravin Shingare, former head of the Directorate of Medical Education and Research (DMER). “If you look at Grant Medical College, 80% seats in super specialty have been lying vacant for 10 years. At GS Medical College, 40% seats in the last 4-5 years have been unfilled,” he added. But the trend has extended to the non-surgical branches too in the past three years. The bias in selecting programmes often is dictated by considerations that in the case of a surgical branch, a candidate needs to work with a team, have an operation theatre, but a clinical course allows the doctor to work independently out of a clinic.

Parent representative Sudha Shenoy said the problem also lies with the long bond that candidates need to serve if they join a government college. “Any candidate who joins a super specialty programme would be at least 30 years old. If they have to serve a 10-year bond, when will they start earning? So, government hospitals go off most students’ choice list. And when it comes to private and deemed institutes, the fee is out of bounds for most,” explained Shenoy

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History & Evolution of Intensive (Critical) Care Units


              The English nurse Florence Nightingale pioneered efforts to use a separate hospital area for critically injured patients. During the Crimean War in the 1850s, she introduced the practice of moving the sickest patients to the beds directly opposite the nursing station on each ward so that they could be monitored more closely.  In 1923, the American neurosurgeon Walter Dandy created a three-bed unit at the Johns Hopkins Hospital. In these units, specially trained nurses cared for critically ill postoperative neurosurgical patients.

           The Danish anaesthesiologist Bjørn Aage Ibsen became involved in the 1952 poliomyelitis epidemic in Copenhagen, where 2722 patients developed the illness in a six-month period, with 316 of those developing some form of respiratory or airway paralysis. Some of these patients had been treated using the few available negative pressure ventilators, but these devices (while helpful) were limited in number and did not protect the patient’s lungs from aspiration of secretions. Ibsen changed the management directly by instituting long-term positive pressure ventilation using tracheal intubation, and he enlisted 200 medical students to manually pump oxygen and air into the patients’ lungs round the clock. At this time, Carl-Gunnar Engström had developed one of the first artificial positive-pressure volume-controlled ventilators, which eventually replaced the medical students. With the change in care, mortality during the epidemic declined from 90% to around 25%. Patients were managed in three special 35-bed areas, which aided charting medications and other management.

        In 1953, Ibsen set up what became the world’s first intensive care unit in a converted student nurse classroom in Copenhagen Municipal Hospital. He provided one of the first accounts of the management of tetanus using neuromuscular-blocking drugs and controlled ventilation.

         The following year, Ibsen was elected head of the department of anaesthesiology at that institution. He jointly authored the first known account of intensive care management principles in the journal Nordisk Medicin, with Tone Dahl Kvittingen from Norway.

      For a time in the early 1960s, it was not clear that specialized intensive care units were needed, so intensive care resources were brought to the room of the patient that needed the additional monitoring, care, and resources. It became rapidly evident, however, that a fixed location where intensive care resources and dedicated personnel were available provided better care than ad hoc provision of intensive care services spread throughout a hospital. In 1962, in the University of Pittsburgh, the first critical care residency was established in the United States. In 1970, the Society of Critical Care Medicine was formed.

How an epidemic led to development of Intensive Care Unit

How an epidemic led to development of Intensive Care Unit

The number of hospital admissions was more than the staff had ever seen. And people kept coming. Dozens each day. They were dying of respiratory failure. Doctors and nurses stood by, unable to help without sufficient equipment.

It was the polio epidemic of August 1952, at Blegdam Hospital in Copenhagen. This little-known event marked the start of intensive-care medicine and the use of mechanical ventilation outside the operating theatre — the very care that is at the heart of abating the COVID-19 crisis.

In 1952, the iron lung was the main way to treat the paralysis that stopped some people with poliovirus from breathing. Copenhagen was an epicentre of one of the worst polio epidemics that the world had ever seen. The hospital admitted 50 infected people daily, and each day, 6–12 of them developed respiratory failure. The whole city had just one iron lung. In the first few weeks of the epidemic, 87% of those with bulbar or bulbospinal polio, in which the virus attacks the brainstem or nerves that control breathing, died. Around half were children.

Desperate for a solution, the chief physician of Blegdam called a meeting. Asked to attend: Bjørn Ibsen, an anaesthesiologist recently returned from training at the Massachusetts General Hospital in Boston. Ibsen had a radical idea. It changed the course of modern medicine.

Student saviours                                    

The iron lung used negative pressure. It created a vacuum around the body, forcing the ribs, and therefore the lungs, to expand; air would then rush into the trachea and lungs to fill the void. The concept of negative-pressure ventilation had been around for hundreds of years, but the device that became widely used — the ‘Drinker respirator’ — was invented in 1928 by Philip Drinker and Louis Agassiz Shaw, professors at the School of Public Health in Boston, Massachusetts. Others went on to refine it, but the basic mechanism remained the same until 1952.

Iron lungs only partially solved the paralysis problem. Many people with polio placed in one still died. Among the most frequent complications was aspiration — saliva or stomach contents would be sucked from the back of the throat into the lungs when a person was too weak to swallow. There was no protection of the airway.

Ibsen suggested the opposite approach. His idea was to blow air directly into the lungs to make them expand, and then allow the body to passively relax and exhale. He proposed the use of a trachaeostomy: an incision in the neck, through which a tube goes into the windpipe and delivers oxygen to the lungs, and the application of positive-pressure ventilation. At the time, this was often done briefly during surgery, but had rarely been used in a hospital ward.

Ibsen was given permission to try the technique the next day. We even know the name of his first patient: Vivi Ebert, a 12-year-old girl on the brink of death from paralytic polio. Ibsen demonstrated that it worked. The trachaeostomy protected her lungs from aspiration, and by squeezing a bag attached to the tube, Ibsen kept her alive. Ebert went on to survive until 1971, when she ultimately died of infection in the same hospital, almost 20 years later.

The plan was hatched to use this technique on all the patients in Blegdam who needed help to breathe. The only problem? There were no ventilators.

Very early versions of positive-pressure ventilators had been around from about 1900, used for surgery and by rescuers during mining accidents. Further technical developments during the Second World War helped pilots to breathe in the decreased pressures at high altitudes. But modern ventilators, to support a person for hours or days, had yet to be invented.

What followed was one of the most remarkable episodes in health-care history: in six-hour shifts, medical and dental students from the University of Copenhagen sat at the bedside of every person with paralysis and ventilated them by hand. The students squeezed a bag connected to the trachaeostomy tube, forcing air into the lungs. They were instructed in how many breaths to administer each minute, and sat there hour after hour. This went on for weeks, and then months, with hundreds of students rotating on and off. By mid-September, the mortality for patients with polio who had respiratory failure had dropped to 31%. It is estimated that the heroic scheme saved 120 people.

Major insights emerged from the Copenhagen polio epidemic. One was a better understanding of why people died of polio. Until then, it was thought that kidney failure was the cause. Ibsen recognized that inadequate ventilation caused carbon dioxide to build up in the blood, making it very acidic — which caused organs to shut down.

Three further lessons are central today. First, Blegdam demonstrated what can be achieved by a medical community coming together, with remarkable focus and stamina. Second, it proved that keeping people alive for weeks, and months, with positive-pressure ventilation was feasible. And third, it showed that by bringing together all the patients struggling to breathe, it was easier to care for them in one place where the doctors and nurses had expertise in respiratory failure and mechanical ventilation.

So, the concept of an intensive-care unit (ICU) was born. After the first one was set up in Copenhagen the following year, ICUs proliferated. And the use of positive pressure, with ventilators instead of students, became the norm.

In the early years, many of the safety features of modern ventilators did not exist. Doctors who worked in the 1950s and 1960s describe caring for patients without any alarms; if the ventilator accidentally disconnected and the nurse’s back was turned, the person would die. Early ventilators forced people to breathe at a set rate, but modern ones sense when a patient wants to breathe, and then help provide a push of air into the lungs in time with the body. The original apparatus also gathered limited information on how stiff or compliant the lungs were, and gave everyone a set amount of air with each breath; modern machines take many measurements of the lungs, and allow for choices regarding how much air to give with each breath. All of these are refinements of the original ventilators, which were essentially automatic bellows and tubing.

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 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons              

Expensive Medical College  seat- Is it worth it?

Mental Health- Depression


Mental health conditions are increasing worldwide. Mainly because of demographic changes, there has been a 13% rise in mental health conditions and substance use disorders in the last decade (to 2017). Mental health conditions now cause 1 in 5 years lived with disability. Around 20% of the world’s children and adolescents have a mental health condition, with suicide the second leading cause of death among 15-29-year-olds. Approximately one in five people in post-conflict settings have a mental health condition.

Mental health conditions can have a substantial effect on all areas of life, such as school or work performance, relationships with family and friends and ability to participate in the community. Two of the most common mental health conditions, depression and anxiety, cost the global economy US$ 1 trillion each year.

Despite these figures, the global median of government health expenditure that goes to mental health is less than 2%. 

Depression

Depression

Key facts

  • Depression is a common mental disorder. Globally, it is estimated that 5% of adults suffer from depression.
  • Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease.
  • More women are affected by depression than men.
  • Depression can lead to suicide.
  • There is effective treatment for mild, moderate, and severe depression.

Overview

Depression is a common illness worldwide, with an estimated 3.8% of the population affected, including 5.0% among adults and 5.7% among adults older than 60 years (1). Approximately 280 million people in the world have depression (1). Depression is different from usual mood fluctuations and short-lived emotional responses to challenges in everyday life. Especially when recurrent and with moderate or severe intensity, depression may become a serious health condition. It can cause the affected person to suffer greatly and function poorly at work, at school and in the family. At its worst, depression can lead to suicide. Over 700 000 people die due to suicide every year. Suicide is the fourth leading cause of death in 15-29-year-olds.

Although there are known, effective treatments for mental disorders, more than 75% of people in low- and middle-income countries receive no treatment (2).  Barriers to effective care include a lack of resources, lack of trained health-care providers and social stigma associated with mental disorders. In countries of all income levels, people who experience depression are often not correctly diagnosed, and others who do not have the disorder are too often misdiagnosed and prescribed antidepressants.

Symptoms and patterns

During a depressive episode, the person experiences depressed mood (feeling sad, irritable, empty) or a loss of pleasure or interest in activities, for most of the day, nearly every day, for at least two weeks. Several other symptoms are also present, which may include poor concentration, feelings of excessive guilt or low self-worth, hopelessness about the future, thoughts about dying or suicide, disrupted sleep, changes in appetite or weight, and feeling especially tired or low in energy. 

In some cultural contexts, some people may express their mood changes more readily in the form of bodily symptoms (e.g. pain, fatigue, weakness).  Yet, these physical symptoms are not due to another medical condition. 

During a depressive episode, the person experiences significant difficulty in personal, family, social, educational, occupational, and/or other important areas of functioning. 

A depressive episode can be categorised as mild, moderate, or severe depending on the number and severity of symptoms, as well as the impact on the individual’s functioning. 

There are different patterns of mood disorders including:

  • single episode depressive disorder, meaning the person’s first and only episode);
  • recurrent depressive disorder, meaning the person has a history of at least two depressive episodes; and
  • bipolar disorder, meaning that depressive episodes alternate with periods of manic symptoms, which include euphoria or irritability, increased activity or energy, and other symptoms such as increased talkativeness, racing thoughts, increased self-esteem, decreased need for sleep, distractibility, and impulsive reckless behaviour.  

Contributing factors and prevention

Depression results from a complex interaction of social, psychological, and biological factors. People who have gone through adverse life events (unemployment, bereavement, traumatic events) are more likely to develop depression. Depression can, in turn, lead to more stress and dysfunction and worsen the affected person’s life situation and the depression itself.

There are interrelationships between depression and physical health. For example, cardiovascular disease can lead to depression and vice versa.

Prevention programmes have been shown to reduce depression. Effective community approaches to prevent depression include school-based programmes to enhance a pattern of positive coping in children and adolescents. Interventions for parents of children with behavioural problems may reduce parental depressive symptoms and improve outcomes for their children. Exercise programmes for older persons can also be effective in depression prevention.

Diagnosis and treatment

There are effective treatments for depression. 

Depending on the severity and pattern of depressive episodes over time, health-care providers may offer psychological treatments such as behavioural activation, cognitive behavioural therapy and interpersonal psychotherapy, and/or antidepressant medication such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Different medications are used for bipolar disorder. Health-care providers should keep in mind the possible adverse effects associated with antidepressant medication, the ability to deliver either intervention (in terms of expertise, and/or treatment availability), and individual preferences. Different psychological treatment formats for consideration include individual and/or group face-to-face psychological treatments delivered by professionals and supervised lay therapists. Antidepressants are not the first line of treatment for mild depression. They should not be used for treating depression in children and are not the first line of treatment in adolescents, among whom they should be used with extra caution.

WHO response

WHO’s Mental Health Action Plan 2013-2030 highlights the steps required to provide appropriate interventions for people with mental disorders including depression. 

Depression is one of the priority conditions covered by WHO’s Mental Health Gap Action Programme (mhGAP). The Programme aims to help countries increase services for people with mental, neurological and substance use disorders through care provided by health workers who are not specialists in mental health. 

WHO has developed brief psychological intervention manuals for depression that may be delivered by lay workers to individuals and groups. An example is the Problem Management Plus manual, which describes the use of behavioural activation, stress management, problem solving treatment and strengthening social support. Moreover, the Group Interpersonal Therapy for Depression manual describes group treatment of depression. Finally, the Thinking Healthy manual covers the use of cognitive-behavioural therapy for perinatal depression.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

REEL Heroes Vs Real Heroes        

 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons              

Expensive Medical College  seat- Is it worth it?

NAIROBI FLY DERMATITIS- Spreading at Sikkim-Paederus dermatitis


Nairobi fly is a common name for two species of rove beetle also called Dragon Bug.

Paederus dermatitis is a peculiar, irritant contact dermatitis characterized by a sudden onset of erythematobullous lesions on exposed areas of the body. The disease is provoked by an insect belonging to the genus Paederus. This beetle does not bite or sting, but accidental brushing against or crushing the beetle over the skin provokes the release of its coelomic fluid, which contains paederin, a potent vesicant agent.

 The fluid contains paederin, a potent vesicant agent. If not immediately washed off, the chemical leads to a linear dermatitis composed of erythematobullous lesions.

NAIROBI FLY DERMATITIS: AROUND 8-10 CASES REPORTED DAILY AT RANGPO PHC

 

NAIROBI FLY DERMATITIS: AROUND 8-10 CASES REPORTED DAILY AT RANGPO PHC

GANGTOK,: Blister Bee Dermatitis, also known as Nairobi Fly Dermatitis, has been spreading rapidly at different places in Sikkim with Sikkim Manipal Institute of Technology, Duga, IBM and Rangpo being the worst-affected.

Nairobi fly is a common name for two species of rove beetle in the genus Paederus, native to East Africa. The beetle contains a toxic hemolymph known as pederin which can cause chemical burns if it comes into contact with skin. Because of these burns, the Nairobi fly is sometimes referred to as a dragon bug. The symptoms include skin inflammation, rashes and blisters in severe cases.

The rash usually affects body parts not covered by clothing; healing time ranges from 7 to 28 days, usually with permanent skin discoloration.

A local guardian of a student at SMIT stated that, “Nairobi fly is reportedly spreading in and around SMIT campus like wildfire and has already infected almost hundred students with its poisonous acid among which one had to undergo a minor hand operation.”

Rangpo PHC, the main health centre in the region, has been receiving around 8-10 cases daily.

“We have getting around 8 to10 cases per day from Duga, Tamatar, IBM and Rangpo areas. I learnt about the cases at SMIT on June 30. I stay in SMIT itself in the staff quarter and almost 60 students from SMIT boys’ hostel have been infected by Nairobi Fly Dermatitis,” sadi Dr. Sandhya Rai.

“The beetle breeds on mushy areas and SMIT boys’ hostel is located along the riverside and maybe the cases are more there because the Nairobi fly breeds on mushy and humid areas,” she added.

Dr. Rai maintained that the infection is not fatal and treatable with oral treatments. She further informed that the beetle, like any other insect and bug, is attracted to light and urged people to use dim lights at night. The beetle does not bite or sting, but the burn is caused when the beetle is slightly or completely squashed, she added.

“The preventive measures include typical anti-vector precautions, including bed nets, long-sleeve clothing, and avoiding fluorescent lights. If the beetles are found on the skin, brushing them off, rather than crushing them, avoids producing dermatitis and spraying pesticides from time to time.”

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How to Prevent/ Manage Mountain Sickness or Altitude Sickness?


If you’ve ever hiked up a mountain and felt yourself getting nauseous or lightheaded, you may have experienced altitude sickness, also called mountain sickness. This condition happens when you travel to a high altitude (elevation) too quickly.

It doesn’t happen only to hikers. Just visiting a high-altitude location can cause problems for some. Symptoms happen when your body tries to adjust to the lower air pressure and lower oxygen levels at high altitudes.

  Altitude sickness symptoms can range from uncomfortable to life-threatening. But with some planning and precautions, you can avoid this condition. The best way to prevent it is to move at a slower pace and let your body adjust. If you notice symptoms at high elevation, don’t push yourself to go farther. Get back down to a lower elevation and let your body adjust before moving up, slowly and carefully.

Who is at risk for altitude sickness?

Anyone can get altitude sickness. Your age, sex and general health don’t seem to affect your risk. You may be at higher risk if you:

  • Have a lung or heart condition: Your healthcare provider may recommend avoiding high altitudes if possible.
  • Are pregnant: Talk to you provider before traveling to a high-altitude location.
  • Live at low elevation: Since your body isn’t used to higher altitudes, you have a greater risk for symptoms. If you’re planning a trip to a high-altitude location, be aware of the symptoms of altitude sickness and how to treat it.
  • Previously had altitude sickness: Talk to your provider about prevention and treatment before your next trip.

What is considered a “high elevation” in terms of getting altitude sickness?

Climbing to these elevations can bring on symptoms of altitude sickness:

  • High altitude: 8,000 to 12,000 feet above sea level.
  • Very high altitude: 12,000 to 18,000 feet.
  • Extremely high altitude: 18,000+ feet.

The summit of Mount Everest is over 29,000 feet.

How common is altitude sickness?

Altitude sickness may occur in up to half of people who climb to elevations above 8,000 feet.

What are the different forms of altitude sickness?

Most people who get altitude sickness get AMS, acute mountain sickness. Higher than 10,000 feet, 75% of people will get mild symptoms . There are three categories of AMS:

  • Mild AMS: Symptoms, such as mild headache and fatigue, don’t interfere with your normal activity. Symptoms improve after a few days as your body acclimates. You can likely stay at your current elevation as your body adjusts.
  • Moderate AMS: Symptoms start to interfere with your activities. You may experience severe headache, nausea and difficulty with coordination. You’ll need to descend to start to feel better.
  • Severe AMS: You may feel short of breath, even at rest. It can be difficult to walk. You need to descend immediately to a lower altitude and seek medical care.

Two severe forms of altitude illness occur less frequently but are more serious. Both can be life-threatening. You need to descend immediately and receive medical treatment for:

  • HAPE (High-altitude pulmonary edema): HAPE produces excess fluid on the lungs, causing breathlessness, even when resting. You feel very fatigued and weak and may feel like you’re suffocating.
  • HACE (High-altitude cerebral edema): HACE involves excess fluid on the brain, causing brain swelling. You may experience confusion, lack of coordination and possibly violent behaviour

SYMPTOMS AND CAUSES

What causes altitude sickness?

Altitude sickness results from a rapid change in air pressure and air oxygen levels at higher elevations. You may have symptoms if you travel to a high elevation without giving your body time to adjust to less oxygen. Even if you’re physically fit, you can still experience altitude sickness.

In addition, high altitude and lower air pressure can lead to fluid leaking from blood vessels. Researchers don’t understand exactly why this happens. This leakage causes fluid to build up in your lungs and brain. Ignoring moderate or severe symptoms can lead to a life-threatening situation. What are the symptoms of altitude

Symptoms of altitude sickness?

You’ll likely feel nauseous and lightheaded. You may vomit and have a headache. Different levels of altitude sickness have different symptoms:

Symptoms of mild, short-term altitude sickness usually begin 12 to 24 hours after arriving at high altitude. They lessen in a day or two as your body adjusts. These symptoms include:

  • Dizziness.
  • Fatigue and loss of energy.
  • Shortness of breath.
  • Loss of appetite.
  • Sleep problems.

Symptoms of moderate altitude sickness are more intense and worsen instead of improve over time:

  • Worsening fatigue, weakness and shortness of breath.
  • Coordination problems and difficulty walking.
  • Severe headache, nausea and vomiting.
  • Chest tightness or congestion.
  • Difficulty doing regular activities, though you may still be able to walk independently.

Severe altitude sickness is an emergency. The symptoms are similar to moderate AMS, but more severe and intense. If you start experiencing these symptoms, you must be taken to a lower altitude immediately for medical care:

  • Shortness of breath, even when resting.
  • Inability to walk.
  • Confusion.
  • Fluid buildup in the lungs or brain.

HAPE, when fluid builds up in the lungs, prevents oxygen from moving around your body. You need medical treatment for HAPE. Symptoms include:

  • Cyanosis, when your skin, nails or whites of your eyes start to turn blue.
  • Confusion and irrational behavior.
  • Shortness of breath even when resting.
  • Tightness in the chest.
  • Extreme fatigue and weakness.
  • Feeling like you’re suffocating at night.
  • Persistent cough, bringing up white, watery fluid.

HACE happens when the brain tissue starts to swell from the leaking fluid. You need medical treatment for HACE. Symptoms include:

  • Headache
  • Loss of coordination.
  • Weakness.
  • Disorientation, memory loss, hallucinations.
  • Psychotic behavior.
  • Coma.

DIAGNOSIS AND TESTS

How is altitude sickness diagnosed?

If you get a headache and at least one other symptom with 24 to 48 hours of moving to a higher elevation, it’s most likely altitude sickness. If you’re climbing, a more experienced climber may recognize symptoms of altitude sickness and guide you to get help.

If you have severe altitude sickness, a healthcare provider will ask about your symptoms, activities and location. The provider may perform a physical exam, including listening to your chest.

Will I need tests to diagnose altitude sickness?

You may need a chest X-ray to see if there is any fluid in your chest. In severe cases, your healthcare provider may order a brain MRI or CT scan to check for fluid in the brain.

MANAGEMENT AND TREATMENT

How is altitude sickness treated?

The main treatment for altitude sickness is to move to a lower elevation as quickly

and safely as possible. At the very least, do not go higher. If symptoms are mild, staying at your current elevation for a few days might be enough to improve the symptoms.

Other treatments depend on how severe the symptoms are:

  • Mild altitude sickness: Over-the-counter medicines can relieve headaches. Other symptoms will improve once your body adjusts or you move to a lower altitude.
  • Moderate altitude sickness: Symptoms should improve within 24 hours once you are 1,000 to 2,000 feet lower than you were. Within three days, you should feel completely better.
  • Severe altitude sickness, HACE and HAPE: If you have severe symptoms, you must be taken immediately to an elevation that’s no higher than 4,000 feet. Get to a healthcare provider as soon as possible. You may need hospitalization.

What treatments are available for severe altitude sickness?

Treatments depend on your symptoms:

  • For fluid in the brain (HACE), you may need dexamethasone, a steroid that helps reduce swelling in the brain. Dexamethasone is sometimes prescribed as a preventive medication.
  • For fluid in the lungs (HAPE), you may need oxygen, medication, a lung inhaler or, in severe cases, a respirator.
  • If you need more oxygen, a provider might prescribe acetazolamide, which increases your breathing rate, so you take in more oxygen. The medicine helps your body adjust faster to the higher elevation and reduces symptoms of altitude sickness.

PREVENTION

How can altitude sickness be prevented?

The best way to prevent altitude sickness is to go slow — called acclimatization. This process allows your body time to adjust to the change in oxygen levels. Take your time when traveling up. For instance, spend a day at a point midway up before continuing to ascend.

You can also talk to your healthcare provider about taking acetazolamide before your trip. Taking it 24 hours before traveling to a high altitude and continuing for five days can help prevent altitude sickness. Dexamethasone can also be used preventively, but it can have serious side effects. Talk to your provider before your trip.

OUTLOOK / PROGNOSIS

What’s the outlook for someone with altitude sickness?

Most people who get altitude sickness get the mild form. Once you return to a lower elevation (or stay at your current elevation without climbing higher), symptoms improve.

Are there long-term effects of altitude sickness?

If you take care and move to a lower elevation when you feel symptoms, altitude sickness has no long-term negative effects. You’ll recover within a few days. Once you feel better, you can continue to travel to higher elevations, as long as you do so slowly and carefully.

Can altitude sickness be fatal?

In rare cases, altitude sickness can be life-threatening. If you develop HAPE or HACE, you are at risk for complications such as coma or even death. Get treatment as soon as possible to reduce your risk.

Can altitude sickness be cured?

Altitude sickness is temporary. Once you return to a lower altitude, you’ll feel better. When you begin your ascent again (or on your next climb), make sure to travel slowly to let your body acclimate.

If I’m planning a hike to a very high elevation, how can I hike safely without getting altitude sickness?

These steps can help your body acclimate:

  • Walk up: Start below 10,000 feet and walk to a high altitude instead of driving or flying. If you drive or fly to an elevation higher than 10,000 feet, stay at your first stop for at least 24 hours before going higher.
  • Go slow: Once above 10,000 feet, don’t increase your altitude more than 1,000 feet a day.
  • Rest: Build a rest day into your schedule for every 3,000 feet you climb.
  • “Climb high and sleep low”: If you climb more than 1,000 feet in a day, come down to sleep at a lower altitude.
  • Know your body: Recognize the signs and symptoms of altitude sickness. Move to a lower altitude (or avoid climbing higher) if you notice any symptoms.
  • Stay hydrated: Drink 3-4 quarts of water per day.
  • Avoid alcohol: Alcohol can dehydrate your body. It also has stronger effects at higher elevations, which can impair judgment.
  • Eat carbs: Eat a diet that’s more than 70% carbohydrates.
  • Know the “don’ts”: Avoid tobacco and depressant drugs, such as sleeping pills and tranquilizers.

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   Medical-Consumer protection Act- Pros and Cons

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NMC’s Opaque Policy on Medical College Infrastructure of Disastrous Consequences


        Quality of medical education is a deciding factor for the kind of doctors and hence the character of the treatment that patients are going to get.  Transparency about the infrastructure and faculty of medical college are important and the deciding factors about the credibility of the institute. But the new opaqueness (by National Medical council- NMC) in the system displaying the critical details about medical colleges can have deleterious effects on medical education. The medical students are blind about the claims made by a medical college during inspection for recognition and permission to admit students, which may be not true. There have been many instances and several complaints of ghost faculty in private colleges and mass transfer of faculty during inspection from one government medical college to another.  Not only medical students pay millions to have a seat in private medical colleges, they invest their prime life time in studying medicine. Such opaqueness has a potential to ruin their careers. Medical students will have to work harder to get true information and more careful, about the institute they are getting into.  

NMC’s college infra reports not public, MCI notes taken down too

NMC’s college infra reports not public, MCI notes taken down too

      The National Medical Commission (NMC) does not post college infrastructure assessment reports on its website and has also removed all previous assessment reports posted by the erstwhile Medical Council of India (MCI). So, students or members of the public cannot know what claims were made by a medical college during inspection for recognition and permission to admit students. Why are these assessment reports important? The reports reveal the date of inspection, the names and designation of the inspectors, usually experienced medical faculty from government medical colleges, along with their comments and findings. They reveal what kind of infrastructure existed or was claimed, including inpatient and outpatient load, number of beds and facilities in the teaching hospital and in the college. They reveal the number of faculty shown as employed by the college department-wise. With about 50 new medical colleges opening in 2021, a record for a single year, and especially unusual since it was the peak pandemic year, there were several complaints of ghost faculty in private colleges and mass transfer of faculty during inspection from one government medical college to another. “Not uploading assessment reports shields such substandard colleges with inadequate faculty and infrastructure. They just want to claim more colleges have been opened and that more MBBS seats have been created. It is a numbers game, quality be damned. In the case of private colleges, getting approval without adequate infrastructure or faculty is a windfall as they charge exorbitant fees from students. Usually, approval is given for 100-150 seats. Even at Rs 15 lakh per annum as tuition fees, the college gets to collect Rs 15 crore to Rs 22.5 crore from the first batch,” said a retired professor of a government medical college. “The MCI, which was labelled corrupt and non-functional, used to post the reports of assessments of infrastructure and faculty done according to minimum standard requirements each year,” said Dr Mohammed Khader Meeran, an RTI activist. In response to Dr Meeran’s RTI application seeking college assessment reports of academic years 2020-21 and 2021-22, the NMC said that “the information sought is very voluminous and scattered in various files” and that “it would disproportionately divert the resource of MARB (Medical Assessment & Rating Board) of NMC”.

     Advantages-Disadvantage of being a doctor

     25 factors- why health care is expensive

REEL Heroes Vs Real Heroes

 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

Expensive Medical College  seat- Is it worth it?

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