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Category : All ; Cycle : February 2013
Medical Articles
Feb23
Loss of organ
A mentally retarded boy staying in a orphanage was bought to me with a scrotal swelling. The boy is 14 years old. He looks disturbed because of pain although he was not able to speak. I examined him and found that his scrotum was swollen and very tender.
The ultrasound showed that his testes had rotated and there was no blood supply – meaning it was already dead. His caretaker says its swollen since 5 days. Poor fellow. A normal boy would have come immediately with such a swelling. His mental retardation and absence of parents had led him to loose his organ.
I had to take him up for surgery. On opening his scrotum his testes was totally dead. There was nothing that i could do for an organ that had lost its blood supply for 5 days! In normal circumstances such surgeries taken up immediately after the onset of swelling can save the testes. Most of the times I have observed that if parents are prompt and bring their child in emergency, the testes can be salvaged. If its late, the testes is lost for ever.
I also opened up the normal scrotum and fixed the right side so that he never develops this problem on that side. This is his only testes and if he looses this he will loose his masculine characteristics. Although he was mentally retarded still that organ has its function.


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Feb22
Remove my stones but not my gall bladder
A 30 year old educated female along with her husband came for consultation.
Before I could ask what was her medical problem she said, "Doctor, I have just been diagnosed to have gall stones. Can you remove my stone but keep the Gall bladder? i do not want to lose my organ., I need it for my digestion & I am too young to lose it. Ultimately God must have given it so it must have some inportant function!"
After asking her symptoms, examining her and studying the ultrasonography report I gave my verdict, "You need removal of gall stones. The International Gold Standard treatment for gallstone disease is removal of gall bladder along with stones.
After few seconds of silence, the husband spoke," Doctor I had kidney stones treated. My surgeon only removed the stones but not the Kidney. Why is it that you are saying that we need to remove the Gall bladder? Can we not remove just the stones?"
Intelligent comparision. Almost all patients have this worry – removal of an organ. Generally this worry is more when one is young.


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Feb21
Uncertainties and Agonies
was admitted to this Bhaktivedanta Hospital on 30th Nov, 2012 for hydrocele Surgery Left side.This was infact the third time for the same case (Of course Not here).The first operation was done on 0-05-2012 at Palghat , Kerala (Palana Hospital) when I was on a vacation. I came back to Mumbai by 24th of May. But in course of time , there was again swelling and fluid collection. By September there was heavy swelling and left bladder was hard and reddish. I contacted the Kerala doctor and he advised immediate fluid draining.Hence I went to Kerala on September 30th , and on Oct, 1st met this doctor. He put a tube and fluid was drained. It was done for 8 days.POOR ME TRUSTED THE DOCTOR AND BELIEVED EVERYTHING WAS ALL RIGHT. But it was only beginning of prolonged pain, treatment, uncertainty and agony.


After this October treatment ( the same doctor of Palghat) I came to Mumbai by 14th of October. But when I went to office there was pain and slight swelling.I took some antibiotics as per the advice of Palghat Doctor (10 days) but no effect.

Then I came to Bhaktivedanta Hospital and met Dr. B C Shah (whom I know before, because earlier in 2008 a surgery was done by them). They advised CEFTUM for 7 days and Oflox subsequently. But healing was not there for the wound of second treatment. They suspected some kind of infection of severe type and I was admitted on 30th Nov. On Dec 1st, 2012 a major surgery was done. Lot of muck and some hydrocele was again removed. I was in Surgical care ward, cot no. 3. Biopsy was sent for examination. It took 10 days to get the result .Against all fear (of TB) it was clear. The pus swab taken for culture.(everyday pus and blood was getting discharged unabated found that a bacteria – E coli was responsible for this. This infection was caught at the time of first operation (May, 2012) and it became very powerful by this time and was resistant to majority of antibiotics. Now there is a great relief because we could find out the villan!

Then as per the report an injectios were prescribed & pus discharge stopped on 10th day. But this time I was there for 32 days – A great Hospital Life!!

Dr B C Shah was admirably perseverant, compassionate and balanced. He did not leave me. I have no words to thank Dr Shah and his assistant Dr Sarang.

Behind all this pain and agony what was giving me relief was the spiritual atmosphere in the hospital. Hare Krishna chanting was there 24 Hours.

I was getting up at 4.30 AM in the morning everyday and was gaining enormous strength from the atmosphere.

Hare Krishna

With love to all in this hospital

Email id: srihari1951@yahoo.co.in
Mobile no: 9833851998
Name: K. SREE KV MOHAN


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Feb20
Impacted Fish Bone Makes Swallowing Food Horrifying
Avinash Tahkur, a 45 year male patient resident of Palghar came to me with pain in chest and difficulty in swallowing (dysphagia) since one month. He took treatment form local doctors but with no relief. It was extremely difficult for him to swallow and he would take only liquids. If he would eat solids he would get excruciating pain in chest and would immediately throw out the food. Both he and his wife appeared quiet nervous. They felt it was cancer and his days were numbered. I told him that it would be very difficult for me to draw any conclusions and give him treatment unless endoscopy was done.
I took him to the endoscopy room. He was made to lay down on his left. I sprayed local anesthesia in his mouth and throat. I inserted a Japanese make upper GI flexible videoscope into his food pipe. The culprit was found. There was a large fish bone impacted in his upper part of food pipe. It was impacted since one month and had created ulcers on opposite walls of the food pipe. Using the operating channel of the videoscope, I inserted a Dormia basket. Dormia basket is a tiny apparatus consisting of four wires. In resting position they are close. When opened within the body, it opens up and forms like a cage. I manipulated the dormia basket and trapped the fish bone. I gradually withdrew it from the food pipe without causing any injury to his food pipe. Patient was relived instantaneously. His chest pain reduced and he could swallow water. He went home immediately with some simple medication and followed up in evening His wife was so relieved and thanked me. Her husband could now eat food. I had also take a biopsy of the ulcer just to be 100% sure that it was not cancer.
Such procedure are difficult. While one is doing these kind of procedure one has to be very careful that he does not cause and injury to the food pipe while dis-impacting and removing the foreign body. Even a slightest error can land up the patient for a major surgery. All such procedures are possible if there are good equipments & perfect skills available. In this case what had happened was that patient had accidentally swallowed a large piece of fish bone but not realized it. I have removed dozens of bones by using endoscopes. Often patient is unaware of it. Many times I have removed dentures. They are also quiet difficult. i have removed many coins, toy pieces, & even safety pins in children. So far by God's grace it has always been successful At times it takes longer time and i have to be extremely cool. The patient is constantly breathing and at times moves just at the critical time. The foreign bodies are also many times very difficult to grip. Coins are slippery, bones are sharp and one is worried about injuring the organ while removing. I prefer general anesthesia for children as its very difficult to get co-operation. Also general anesthesia relaxes the sphincters and its easy to pull out foreign bodies. In children general anesthesia protects the airway and reduces the chance of the foreign body accidentally going into the food pipe while removing it.


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Feb19
Cancer
Information on cancer
Cancer is a condition where cells in a specific part of the body grow and reproduce uncontrollably. The cancerous cells can invade and destroy surrounding healthy tissue, including organs.
Cancer sometimes begins in one part of the body before spreading to other areas. This process is known as metastasis.
There are over 200 different types of cancer, each with its own methods of diagnosis and treatment. You can find out more about specific types of cancer by using the links on this page.
Spotting signs of cancer
Changes to your body's normal processes or symptoms that are out of the ordinary can sometimes be an early sign of cancer.
For example, a lump that suddenly appears on your body, unexplained bleeding or changes to your bowel habits are all symptoms that need to be checked by a doctor.
In many cases, your symptoms will not be related to cancer and will be caused by other, non-cancerous health conditions. However, it is still important that you see Dr. B C Shah so your symptoms can be investigated.
Reducing your risk of cancer
Making some simple changes to your lifestyle can significantly reduce your risk of developing cancer. For example, healthy eating, taking regular exercise and not smoking will all help lower your risk.
How common is cancer?
Cancer is a common condition. More than one in three people will develop some form of cancer during their lifetime.
The most common types of cancer are:
Breast cancer
Prostate cancer
Lung cancer
Bowel cancer
Bladder cancer
Uterine (womb) cancer
Cancer treatment
Each specific type of cancer has its own set of treatment methods.
However, many cases of cancer are treated using chemotherapy (powerful cancer-killing medication) and radiotherapy (the controlled use of high energy X-rays). Surgery is also sometimes carried out to remove cancerous tissue.
Waiting times
Accurately diagnosing cancer can take weeks or months. As cancer often develops slowly, over several years, waiting for a few weeks will not usually impact on the effectiveness of treatment.
Patients suspected of having cancer and urgently referred by their doctor, should have no more than a two week wait to see a specialist.
In cases where cancer has been confirmed, patients should wait no more than 31 days from the decision to treat to the start of their treatment.
Signs and symptoms of cancer
It is important to be aware of any unexplained changes to your body, such as the sudden appearance of a lump, blood in your urine or a change in your usual bowel habits
These symptoms are often caused by other, non-cancerous illnesses, but it is important you see Dr. B C Shah so he can investigate.
Other potential signs and symptoms of cancer are outlined below.
Lump in your breast
See Dr. B C Shah if you notice a lump in your breast, or if you have a lump that is rapidly increasing in size elsewhere on your body.
Dr. B C Shah will refer you to a specialist for tests if he thinks you may have cancer.
Coughing, chest pain and breathlessness
You should visit Dr. B C Shah if you have had a cough for more than three weeks.
Symptoms such as shortness of breath or chest pain may be a sign of an acute (severe) condition, such as pneumonia (a lung infection). Go to see Dr. B C Shah straight away if you experience these types of symptoms.
Changes in bowel habits
Go to see Dr. B C Shah if you have experienced one of the changes listed below and it has lasted for more than a few weeks:
blood in your stools
diarrhoea or constipation for no obvious reason
a feeling of not having fully emptied your bowels after going to the toilet
pain in your abdomen (tummy) or your anus (back passage)
persistent bloating
Bleeding
You should also go to see Dr. B C Shah if you have any unexplained bleeding such as:
Blood in your urine
Bleeding between periods
Blood from your back passage
Blood when you cough
Blood in your vomit
Moles
Go to see Dr. B C Shah if you have a mole that:
Has an irregular or asymmetrical shape
Has an irregular border with jagged edges
Has more than one colour (it may be flecked with brown, black, red, pink or white)
Is bigger then 7mm in diameter
Is itchy, crusting or bleeding
Any of the above changes means that there is a chance you have malignant melanoma (skin cancer).
Unexplained weight loss
You should also go to see Dr. B C Shah if you have lost a lot of weight over the last couple of months that cannot be explained by changes to your diet, exercise or stress.


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Feb18
Cardiovascular Disease
Introduction
Coronary heart disease (CHD) is the biggest killer, around one in five men and one in seven women die from the disease.
CHD affects more men than women, and your chances of getting it increase as you get older.
About the heart
The heart is a muscle that is about the size of your fist. It pumps blood around your body and beats approximately 70 times a minute. After the blood leaves the right side of the heart, it goes to your lungs where it picks up oxygen.
The oxygen-rich blood returns to your heart and is then pumped to the organs of your body through a network of arteries. The blood returns to your heart through veins before being pumped back to your lungs again. This process is called circulation.
The heart gets its own supply of blood from a network of blood vessels on the surface of your heart, called coronary arteries.
Coronary heart disease
Coronary heart disease is the term that describes what happens when your heart's blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries.
Over time, the walls of your arteries can become furred up with fatty deposits. This process is known as atherosclerosis and the fatty deposits are called atheroma. If your coronary arteries become narrow due to a build-up of atheroma, the blood supply to your heart will be restricted. This can cause angina (chest pains).
If a coronary artery becomes completely blocked, it can cause a heart attack. The medical term for a heart attack is myocardial infarction.
By making some simple lifestyle changes, you can reduce your risk of getting CHD. If you already have heart disease, you can take steps to reduce your risk of developing further heart-related problems. Keeping your heart healthy will also have other health benefits, and help reduce your risk of stroke and dementia.
Symptoms of coronary heart disease
If your coronary arteries become partially blocked, it can cause chest pain (angina). If they become completely blocked, it can cause a heart attack (myocardial infarction).
Some people experience different symptoms, including palpitations and unusual breathlessness. In some cases, people may not have symptoms of coronary heart disease (CHD) at all before they are diagnosed.
Angina
Angina is a symptom of CHD. It can be a mild, uncomfortable feeling that is similar to indigestion. However, a severe angina attack can cause a feeling of heaviness or tightness, usually in the centre of the chest, which may spread to the arms, neck, jaw, back or stomach.
Angina is often triggered by physical activity or stressful situations. The symptoms usually pass in less than 10 minutes and can be relieved by resting or using a nitrate tablet or spray.
Heart attacks
Heart attacks can cause permanent damage to the heart muscle and, if not treated straight away, can be fatal.
The discomfort or pain of a heart attack is similar to that of angina but it is often more severe. During a heart attack you may also experience the following symptoms:
Sweating
Light-headedness
Nausea
Breathlessness
The symptoms of a heart attack can be similar to indigestion. For example, they may include a feeling of heaviness in your chest, a stomach ache or heartburn. A heart attack can happen at any time, including while you are resting. If heart pains last longer than 15 minutes, it may be the start of a heart attack.
Unlike angina, the symptoms of a heart attack are not usually relieved using a nitrate tablet or spray.
Heart failure
Heart failure can occur in people with CHD. The heart becomes too weak to pump blood around the body, which can cause fluid to build up in the lungs, making it increasingly difficult to breathe. Heart failure can happen suddenly (acute heart failure) or gradually, over time (chronic heart failure).
Causes of heart disease
Coronary heart disease (CHD) is usually caused by a build-up of fatty deposits on the walls of the coronary arteries. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.
The build-up of atheroma on the walls of the coronary arteries makes the arteries narrower and restricts the flow of blood to the heart. This process is called atherosclerosis. Your risk of developing atherosclerosis is significantly increased if you:
Smoke
Have high blood pressure
Have a high blood cholesterol level
Do not take regular exercise
Have diabetes
Other risk factors for developing atherosclerosis include:
Being obese or overweight
Having a family history of CHD: the risk is increased if you have a male relative with CHD under 55 or a female relative under 65
Cholesterol
Cholesterol is a fat made by the liver from the saturated fat that we eat. Cholesterol is essential for healthy cells, but if there is too much in the blood it can lead to CHD.
Cholesterol is carried in the blood stream by molecules called lipoproteins. There are several different types of lipoproteins, but two of the main ones are low-density lipoproteins (LDL) and high-density lipoproteins (HDL).
LDL, often referred to as bad cholesterol, takes cholesterol from the liver and delivers it to cells. LDL cholesterol tends to build up on the walls of the coronary arteries, increasing your risk of heart disease. HDL, often referred to good cholesterol, carries cholesterol away from the cells and back to the liver, where it is broken down or passed from the body as a waste product.
The current government recommendation is that you should have a total blood cholesterol level of less than 5mmol/litre, and an LDL cholesterol level of under 3mmol/litre and this should be even lower if you have symptoms of CHD.
High blood pressure
High blood pressure (hypertension) puts a strain on your heart and can lead to CHD.
Blood pressure is measured at two points during the blood circulation cycle. The systolic pressure is a measure of your blood pressure as the heart contracts and pumps blood out. The diastolic pressure is a measure of your blood pressure when your heart is relaxed and filling up with blood.
Blood pressure is measured in terms of millimetres of mercury (mmHg). When you have your blood pressure measured, the systolic pressure is the first, higher number to be recorded. The diastolic pressure is the second, lower number to be recorded. High blood pressure is defined as a systolic pressure of 140mmHg or more, or a diastolic pressure of 90mmHg or more.
Smoking
Smoking is a major risk factor. Carbon monoxide (from the smoke) and nicotine both put a strain on the heart by making it work faster. They also increase your risk of blood clots.
Other chemicals in cigarette smoke damage the lining of your coronary arteries, leading to furring of the arteries. If you smoke, you increase your risk of developing heart disease by 24%.
Thrombosis
A thrombosis is a blood clot within an artery (or a vein). If a thrombosis occurs in a coronary artery (coronary thrombosis), it will cause the artery to narrow, increasing your chance of having a heart attack as the blood clot prevents the blood supply from reaching the heart muscle. Coronary thrombosis usually happens at the same place as where atherosclerosis is forming (furring of the coronary arteries).
Diagnosis and risk assessment
If your doctor thinks you may be at risk of developing coronary heart disease (CHD), they may carry out a risk assessment for cardiovascular disease, heart attack or stroke.
Your doctor will ask about your medical and family history, check your blood pressure and do a blood test to assess your cholesterol level.
Before having the cholesterol test, you may be asked not to eat for 12 hours so there is no food in your body that could affect the result. Dr. B C Shah can carry out the blood test and will take a sample either using a needle and a syringe or by pricking your finger.
Dr. B C Shah will also ask about your lifestyle, how much exercise you do and whether you smoke. All these factors will be considered as part of the diagnosis.
To confirm a suspected diagnosis you may be referred for more tests. A number of different tests are used to diagnose heart-related problems including:
Electrocardiogram (ECG)
X-rays
Echocardiogram
Blood tests
Coronary angiography
Radionuclide tests
Magnetic resonance imaging (MRI)
Electrocardiogram (ECG)
An ECG records the rhythm and electrical activity of your heart. A number of electrodes (small, sticky patches) are put on your arms, legs and chest. The electrodes are connected to a machine that records the electrical signals of each heartbeat.
Although an ECG can detect problems with your heart rhythm, an abnormal reading does not always mean that there is anything wrong, nor does a normal reading rule out heart problems.
In some cases you may have an exercise ECG test or 'stress test'. This is when an ECG recording is taken while you are exercising (usually on a treadmill or exercise bike). If you experience pain while exercising, the test can help to identify whether your symptoms are caused by angina, which is usually due to CHD.
X-rays
An x-ray may be used to look at the heart, lungs and chest wall. This can help to rule out any other conditions which may be causing your symptoms.
Echocardiogram (echo)
An echocardiogram is similar to the ultrasound scan used in pregnancy. It produces an image of your heart using sound waves. The test can identify the structure, thickness and movement of each heart valve and can be used to create a detailed picture of the heart.
During an echocardiogram you will be asked to remove your top and a small handheld device, called a transducer, will be passed over your chest. Lubricating gel is put onto your skin to allow the transducer to move smoothly and make sure there is continuous contact between the sensor and the skin.
Blood tests
In addition to cholesterol testing, you may need to have a number of blood tests that are used to monitor the activity of the heart. These include cardiac enzyme tests, which can show whether there is damage to the heart muscle, and thyroid function tests.
Coronary angiography
Coronary angiography, also known as a catheter test, is usually performed under local anaesthetic. As well as providing information about your heart's blood pressure and how well your heart is functioning, an angiogram can also identify whether the coronary arteries are narrowed and how severe any blockages are.
In an angiogram, a catheter (flexible tube) is passed into an artery in your groin or arm and it is guided into the coronary arteries using X-rays. A dye is injected into the catheter to show up the arteries supplying your heart with blood. A number of X-ray pictures are taken, which will highlight any blockages.
A coronary angiogram is a relatively safe procedure and serious complications are rare. The risk of having a heart attack, stroke or dying during the procedure is estimated at about one or two in every 1,000. However, after having a coronary angiogram, you may experience some minor side effects including:
A slightly strange sensation when the dye is put down the catheter
A small amount of bleeding when the catheter is removed
A bruise in your groin or arm
Radionuclide tests
Radionuclide tests are used to diagnose CHD. They can also indicate how strongly your heart pumps and show the flow of blood to the muscular walls of your heart. Radionuclide tests provide more detailed information than the exercise ECG test.
During a radionuclide test, a small amount of a radioactive substance, called an isotope, is injected into your blood (sometimes during exercise). If you have difficulty exercising, you may be given some medication to make your heart beat faster. A camera placed close to your chest picks up the radiation transmitted by the isotope as it passes through your heart.
Magnetic resonance testing (MRI)
An MRI scan can be used to produce detailed pictures of your heart. During an MRI scan, you lie inside a tunnel-like scanner that has a magnet around the outside. The scanner uses a magnetic field and radio waves to produce detailed images.
Treating heart disease
What is good care for heart disease?
Effective treatment of coronary heart disease (CHD) saves lives. Since 2000, there has been a 40% reduction in deaths from heart disease in people under 75. A national review of heart disease services set out standards that define good heart disease care:
Tackling the factors that increase the risk of heart disease, such as smoking, poor diet and little physical exercise
Preventing CHD in high-risk patients and where patients have CHD, avoiding complications and tackling the progression of the disease
Rapid treatment for heart attack, including the choice of angioplasty in a specialist cardiac centre
Rapid diagnosis of heart disease and access to diagnostic tests
Rapid access and choice of treatment centre for specialised cardiac care
Treatment overview
CHD cannot be cured but it can be managed effectively with a combination of lifestyle changes, medicine and in some cases surgery. With the right treatment, the symptoms of CHD can be reduced and the functioning of the heart improved.
Recovering from heart disease
The purpose of cardiac rehabilitation is to help you to recover and resume a normal life as soon as possible after having a heart transplant, a coronary angioplasty or coronary artery bypass surgery. It may also be useful if you have other heart-related conditions, such as a heart attack, angina or heart failure.
Cardiac rehabilitation programme
If you have heart surgery, a member of the cardiac rehabilitation team may visit you in hospital to give you information about your condition and the procedure that you are having. This care will usually continue after you have left hospital. For the first few weeks following your surgery, a member of the cardiac rehabilitation team may visit you at home or call you to check on your progress.
What happens in cardiac rehabilitation programmes can vary widely throughout the country but most will cover the following basic areas:
Exercise
Education
Relaxation and emotional support
Once you have completed your rehabilitation programme, it is important that you continue to take regular exercise and lead a healthy lifestyle. This will help to protect your heart and reduce the risk of further heart-related problems.
Self-care
Self-care is an integral part of daily life and is all about you taking responsibility for your own health and wellbeing with support from the people involved in your care. Self-care includes the actions you take for yourself every day in order to stay fit and maintain good physical and mental health, prevent illness or accidents and care more effectively for minor ailments and long-term conditions.
People living with long-term conditions can benefit enormously from being supported so they reach self-care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life and be more active and independent.
Support groups
If you have or have had a heart condition or if you are caring for someone with a heart condition, you might find it useful to meet other people in your area who are in a similar situation.
Relationships and sex
Coming to terms with a long-term condition such as heart disease can put a strain on you, your family and your friends. It can be difficult to talk with people about your condition, even if they are close to you. Be open about how you feel and let your family and friends know what they can do to help. But do not feel shy about telling them that you need some time to yourself.
Your sex life
If you have coronary heart disease (CHD) or you have recently had heart surgery, you may be concerned about having sex. Usually, as soon as you feel well enough, you can resume sexual activity. Communicate with your partner and stay open-minded. Explore what you both like sexually. Simply touching, being touched and being close to someone helps a person feel loved and special.
Returning to work
After recovering from heart surgery, you should be able to return to work, but it may be necessary to change the type of work that you do. For example, you may not be able to do a job that involves heavy physical exertion. Dr. B C Shah will be able to advise you about when you can return to work, and what type of activities you should avoid.


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Feb17
Peripheral arterial disease – Treatment
Introduction

Peripheral arterial disease (PAD) is a common condition in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles. It is also known as peripheral vascular disease (PVD).

Although many people with PAD have no symptoms, some people have painful aching in their legs brought on by walking. These aches will usually disappear after a few minutes of resting.

If you experience recurring leg pain with exercise, see Dr B C Shah. PAD is usually diagnosed through a physical examination by Dr B C Shah.

They will also measure the blood pressure in your leg, using the ankle brachial pressure index (ABPI). This involves comparing blood pressure readings from your arm and your ankle. A difference between these readings may indicate PAD.
Why does it happen?

Peripheral arterial disease is a cardiovascular disease, meaning it affects blood vessels. It’s usually caused by a build-up of fatty deposits in the walls of the leg arteries. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.

The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis.
Who is affected?

Rates of cases of PAD are strongly associated with older age. It is estimated that it develops in:
2.5% of people under 60
8.3% of people aged 60–69
19% of people over 70

Men are more likely to develop the symptoms of PAD earlier in life than women.

There are certain things that can increase your chances of developing PAD and other cardiovascular diseases, including:
Smoking –by far the single most significant risk factor
Diabetes – both type 1 and type 2 diabetes
High blood pressure
High cholesterol
Treating and preventing peripheral arterial disease

PAD is largely treated through medication and lifestyle changes.

Completely stopping smoking and exercising regularly are the main lifestyle changes that can ease the symptoms of PAD and reduce the chances of the condition worsening.

The underlying causes should also be treated, such as reducing high blood pressure and cholesterol and treating diabetes. Medication can be used to improve blood flow. In some cases, surgery may be needed to treat PAD.
Complications of peripheral arterial disease

While PAD is not immediately life-threatening, the process of atherosclerosis that caused it can lead to serious problems.

Having PAD means you have a much higher risk of developing other serious cardiovascular diseases, such as:
coronary heart disease – a condition where the supply of blood to the heart is restricted, putting you at risk of a heart attack
stroke

Also, if the symptoms of PAD worsen, there is a risk that tissue of the lower leg will begin to die (this is known as gangrene), which in severe cases requires the lower leg to be amputated.

If treatment is successful, and lifestyle changes are maintained, your situation will usually improve.

However, if you are unable or unwilling to make lifestyle changes, especially if your leg pain is getting worse, it is estimated there is a:
One-in-five chance you will experience a non-fatal heart attack or stroke
5% chance that one or both of your legs will need to be amputated
One-in-three chance you will die prematurely

Symptoms of peripheral arterial disease

Many people with peripheral arterial disease (PAD) do not have any symptoms. However, you may feel painful aching in your leg muscles triggered by physical activity such as walking or climbing stairs.

The pain usually develops in your calves, but sometimes your hip, buttock or thigh muscles can be affected. The pain can range from mild to severe.

The pain will usually go away after 5–10 minutes when you rest your legs. Other symptoms of PAD may include:
Hair loss on your legs and feet
Numbness or weakness in the legs
Brittle, slow-growing toenails
Ulcers (open sores) on your feet and legs, which do not heal
Changing skin colour on your legs, turning pale or bluish
Shiny skin
The muscles in your legs may shrink
Men may develop impotence (erectile dysfunction)
When to seek medical advice

If you experience recurring episodes of leg pain, make an appointment with Dr. B C Shah, especially if you are a smoker or have a confirmed diagnosis of diabetes, high blood pressure and/or high cholesterol.

Many people mistakenly think recurring episodes of leg pain are part of growing older. This is not the case. There is no reason why an otherwise healthy person should experience leg pain.
When to seek urgent medical advice

Some symptoms may suggest the supply of blood to your legs has become severely restricted and you may need to see a doctor urgently. These include:
Being unable to move muscles in the affected leg
A sudden loss of normal sensation in the affected leg
Feeling a burning or prickling sensation in the affected leg
Your toes or leg suddenly turns white or blue
The skin on your toes or lower limbs becomes cold and numb, and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain
Causes of peripheral arterial disease

Peripheral arterial disease (PAD) is usually caused by a build-up of fatty deposits on the walls of the arteries inside the legs. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.

The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis.

People with PAD can experience painful aching in their leg muscles during physical activity because the muscles are not receiving the blood supply they need.

Like all tissue in your body, muscles in your legs need a constant supply of blood to function properly. When you are using your leg muscles, the demand for blood increases four-fold. But if the arteries in your legs are blocked, the supply of available blood cannot meet the demand.

This shortfall between supply and demand causes your muscles to experience painful aches which usually get better when you rest your legs.
Increased risk of PAD

There are some things that cannot be changed which may increase your chances of developing PAD, such as a family history of heart disease and atherosclerosis, or your age.

As you get older, your arteries naturally begin to harden and get narrower, which can lead to atherosclerosis and then PAD.

However, there are many things that can dangerously speed up this process. These are described below.
Smoking

Smoking is the single most important thing that increases your risk of PAD. Smoking can damage the walls of your arteries. Tiny blood cells, known as platelets, will then form at the site of the damage to try to repair it. This can cause your arteries to narrow.

It is estimated that smokers are six times more likely to develop PAD than non-smokers and more than 80% of people who develop PAD are current or former smokers.
Diabetes

If you have poorly controlled type 1 or type 2 diabetes, the excess glucose in your blood can damage your arteries.

People with diabetes are two to four times more likely to develop PAD, and having a combination of poorly controlled diabetes and PAD is a major risk factor for amputation. People with diabetes and PAD are 15 times more likely to need an amputation than people with PAD who do not have diabetes.
High cholesterol

Cholesterol is a type of fat essential for the body to function.

There are two main types of cholesterol:
Low-density lipoprotein (LDL) is the main cholesterol transporter and carries cholesterol from your liver to cells that need it. If there is too much cholesterol for the cells to use, this can cause a harmful build-up in your blood and lead to atherosclerosis. For this reason, LDL cholesterol is known as "bad cholesterol", and lower levels are better.
High-density lipoprotein (HDL) carries cholesterol away from the cells and back to the liver, where it is either broken down or passed from the body as a waste product. For this reason, it is referred to as "good cholesterol", and higher levels are better.

Most of the cholesterol your body needs is made by your liver. However, if you eat foods high in saturated fat, the fat is broken down into LDL ("bad cholesterol").l.
High blood pressure

Your arteries are designed to pump blood at a certain pressure, and if blood pressure is too high (known as hypertension), the walls of the arteries can become damaged. High blood pressure can be caused by:
Being overweight
Drinking excessive amounts of alcohol
Stress
Smoking
A lack of exercise
Homocysteine

Homocysteine is a type of amino acid (molecule that makes up protein) found in the blood. Research has found that 30%–40% of people with PAD have higher-than-average levels of homocysteine in their blood. And one-in-four people who develop leg pain have extremely high levels.

It has been suggested that high levels of homocysteine may damage the walls of the arteries, leading to atherosclerosis, but this has not been proven.

Vitamin B supplements and eating foods high in folic acid, such as green leafy vegetables or wholegrains, are known to lower homocysteine levels. However, researchers found no significant reduction in risk of cardiovascular disease when people with PAD increased the amount of vitamin B and folic acid in their diet.
Diagnosing peripheral arterial disease

If Dr. B C Shah suspects a diagnosis of peripheral arterial disease (PAD), he will carry out a physical examination of your leg.

PAD can cause a number of noticeable signs and symptoms, such as:
Shiny skin
Brittle toenails
Hair loss
The pulse in your leg being very weak or undetectable
Leg ulcers

Dr B C Shah may also ask about your symptoms and personal and family medical histories.
The ankle brachial pressure index

The ankle brachial pressure index (ABPI) test is widely used to diagnose PAD, as well as assessing how well you are responding to treatment.

While you rest on your back, Dr B C Shah will measure the blood pressure in your upper arm and your ankle. These measurements are taken with a Doppler probe, which uses sound waves to determine the flow of blood in your arteries.

They then divide the second result (from your ankle) by the first result (from your arm).

If your circulation is healthy, the blood pressure in both parts of your body should be exactly or almost the same and the result of your ABPI would be 1.

But if you have PAD, the blood pressure in your ankle will be lower due to a reduction in blood supply, so the results of the ABPI would be less than 1.

In some cases, ABPI may be carried out after getting you to run on a treadmill or cycle on an exercise bike. This is a good way of seeing the effect of physical activity on your circulation.
Further testing

In most cases, Dr B C Shah will be able to confirm a diagnosis of PAD by doing a physical examination, asking about your symptoms and checking your ABPI score.

Further testing is usually only required if:
There is uncertainly about the diagnosis – for example, if you have symptoms of leg pain but your ABPI score is normal.
You do not fit the expected profile of somebody with PAD; for example, you are under 40 and have never smoked.
The restriction of blood supply in your leg is severe enough that treatment may be required.

Additional hospital-based tests that can be used include:
Ultrasound scan – where sound waves are used to build up a picture of arteries in your leg. This can identify exactly where in your arteries there are blockages or narrowing.
Angiogram – a special liquid known as a contrast agent is injected into a vein in your arm. The agent shows up clearly on a computerised tomography (CT) scan or magnetic resonance imaging (MRI) scan and produces a detailed image of your arteries.

In some cases, the contrast agent may be injected directly into the arteries of your leg and X-rays may be used to produce the images.
Treating peripheral arterial disease

There are two main types of treatment used in the management of peripheral arterial disease (PAD).

These are:
Making lifestyle changes to improve symptoms and reduce your risk of developing a more serious cardiovascular disease (CVD), such as coronary heart disease
Taking medication to address the underlying cause of PAD and reduce your risk of developing another CVD. For example, a statin can be used to lower your cholesterol levels.

Surgery may be used in some cases. For example, if you experience pain in your leg while resting or if there is tissue loss. These treatment types are discussed in more depth below.
Lifestyle changes

The two most important lifestyle changes you can make if you are diagnosed with PAD are:
If you currently smoke, you should stop.
Take regular exercise.
Smoking

Quitting smoking will reduce your risk of PAD getting worse and another serious cardiovascular disease developing.

Research has found people who continue to smoke after receiving their diagnosis are five times more likely to have a heart attack and seven times more likely to die from a complication of heart disease than people who quit after receiving their diagnosis.

People who stop smoking usually notice an improvement in their symptoms and an improvement in their ankle brachial pressure index (ABPI) score.
Exercise

Evidence suggests regular exercise helps reduce the severity and frequency of PAD symptoms, while at the same time reducing the risk of developing another CVD.

Research has found that after six months of regular exercise, a person can::
Walk for two to three times longer before experiencing pain
Walk a lot further before experiencing pain
see a 20% improvement in their ABPI score

If you are diagnosed with PAD, it is likely you have not taken part in regular exercise for many years (although this is not true for everyone, such as previously fit people with type 1 diabetes).

The exercise programme usually involves two hours of supervised exercise a week for three months. But ideally, over time, you should be aiming to exercise daily for the rest of your life, as the benefits of exercise are quickly lost if it is not frequent and regular.

The preferred exercise is walking. It is normally recommended you walk as far and as long as you can before the symptoms of pain become intolerable. Once this happens, rest until the pain goes and begin walking again until the pain returns. Keep using this "stop-start" method until you have spent at least 30 minutes walking.

You will probably find the exercise course challenging, as the frequent episodes of pain can be upsetting and off-putting. But if you persevere, you should gradually notice a marked improvement in your symptoms and you will begin to go longer and longer without experiencing any pain.
Medication

Different medications can be used to treat the underlying causes of PAD while reducing your risk of developing another CVD.

Some people may only need to take one or two of the medications discussed below, while others may need all of them.
Statins

If blood tests show that your levels of LDL cholesterol ("bad cholesterol") are high, you will be prescribed a type of medication called a statin.

Statins work by helping to reduce the production of LDL cholesterol by your liver.

Common side effects of statins include:
Digestive disorders, such as constipation and diarrhoea
Difficulty sleeping (insomnia)
Pain in the muscles and joints
Feeling sick (nausea)
Antihypertensives

Antihypertensives are a group of medications used to treat high blood pressure (hypertension).

It is likely you will be prescribed an antihypertensive drug if your blood pressure is higher than 140/90mmHg if you do not have diabetes, or 130/80mmHg if you do have diabetes.

A widely used type of antihypertensive is an angiotensin-converting enzyme (ACE) inhibitor.

ACE inhibitors block the actions of some hormones that help regulate blood pressure. They help to reduce the amount of water in your blood and widen your arteries, which will both decrease your blood pressure.

Side effects of ACE inhibitors include:
Dizziness
Tiredness or weakness
Headaches
A persistent dry cough

Most of these side effects pass in a few days, although some people find they still have a dry cough.

If side effects become particularly troublesome, a medication that works in a similar way to ACE inhibitors, known as an angiotensin-2 receptor antagonist, may be recommended.

ACE inhibitors can cause unpredictable effects if taken with other medications, including some over-the-counter ones, so check with Dr B C Shah before taking anything in combination with this medication.
Antiplatelets

One of the biggest potential dangers if you have atherosclerosis is a piece of fatty deposit (plaque) breaking off from your artery wall. This can cause a blood clot to develop at the site of the broken plaque.

If a blood clot develops inside an artery that supplies the heart with blood (a coronary artery) it can trigger a heart attack. Similarly, if a blood clot develops inside any of the blood vessels going to the brain, it can trigger a stroke.

You will probably be prescribed an antiplatelet medication to reduce your risk of blood clots. This medication reduces the ability of platelets (tiny blood cells) to stick together, so if a plaque does break apart, you have a lower chance of a blood clot developing.

Low-dose aspirin (usually 75mg a day) is usually recommended.

Common side effects of aspirin include:
Irritation of the stomach or bowel
Indigestion
Nausea (feeling sick)

If you are unable to take aspirin (for example, if you have a history of stomach ulcers or you are allergic to aspirin), an alternative antiplatelet called clopidogrel can be used.

Side effects of clopidogrel include:
Diarrhoea
Pains in your stomach and bowel
Nosebleeds
Bruising
Blood in your urine
Blood in your stools
Naftidrofuryl oxalate

Naftidrofuryl oxalate improves blood flow in the body, and is often used if you prefer not to have surgery or your supervised exercise programme has not led to satisfactory improvement in your condition.

Side effects of naftidrofuryl oxalate include:
Dizziness
Headache
Stomach pains
Diarrhoea
Rashes
Surgery

There are two main types of surgical treatment for PAD:
Angioplasty – where a blocked or narrowed section of artery is widened by inflating a tiny balloon inside the vessel
Bypass graft – where blood vessels are taken from another part of your body and used to bypass the blockage in an artery
Angioplasty vs bypass surgery

Both types of surgery have their own set of pros and cons.

An angioplasty is less invasive (it does not involve making major incisions in your body). It is usually performed under a local anaesthetic as a day procedure. This means you will be able to go home the same day you have the operation. You also feel less pain after an angioplasty. However, the improvement in symptoms varies from person to person and may only last for around 6-12 months.

Bypass surgery, which is usually only used when angioplasty is not suitable or if it has failed, has a longer recovery time (around two to three weeks). However, the improvement in symptoms usually lasts for longer than a year.

However, after two years, both techniques have broadly the same success rate of improving symptoms.

Both techniques carry a risk of causing serious complications such as a heart attack, stroke and even death. One study found that the risk of death for angioplasty was around one person in every 200, and the risk for bypass graft was slightly higher – around two to three people in every 100.

Before recommending treatment, a team of specialist surgeons, doctors and nurses will discuss the options with you – including the potential risks and benefits.

Surgery is not always successful in treating PAD and is usually only recommended under the following circumstances:
Your leg pain is so severe it prevents you from carrying out everyday activities.
Your symptoms have failed to respond to treatments discussed above.
The results of tests, such as ultrasound scans, show surgery is likely to improve symptoms.

Both techniques are discussed in more detail below.
Angioplasty

A tiny hollow tube known as a catheter is inserted into one of the arteries in your groin. The catheter is then guided to the site of the blockage.

On the tip of the catheter is a balloon which is inflated when the catheter is in place. This helps widen the vessel. Sometimes a hollow metal tube known as a stent may be left in place to help keep the artery open.

Read more about angioplasty.
Bypass graft

If angioplasty is unsuccessful or unsuitable, a bypass graft may be performed. During surgery a length of a healthy vein in your leg is removed. The vein is then joined (grafted) above and below the blocked vein so the blood supply can be rerouted, or bypassed, through the healthy vein. Sometimes a section of artificial tubing can be used as an alternative to a grafted vein.
Complications of peripheral arterial disease

The build up of fat in the arteries (atherosclerosis) that causes peripheral arterial disease (PAD) can also lead to other serious conditions.
Critical limb ischemia (CLI)

Critical limb ischemia (CLI) is a condition that occurs when blood flow to the limbs is severely restricted from atherosclerosis.

Symptoms of CLI include:
A severe burning pain in your legs and feet even when you are resting; the pain often occurs at night and episodes of pain can last several hours. You may find you have to hang your legs out of bed to get relief.
Your skin turns pale, shiny, smooth and dry.
You may develop wounds and ulcers (open sores) in your feet and legs that show no sign of healing.
The muscles in your legs begin to waste away.
The skin on your toes or lower limbs becomes cold and numb and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain.

If you think you are developing the symptoms of CLI, contact Dr. B C Shah immediately.

CLI is treated using an angioplasty or bypass graft (Read about treating peripheral arterial disease for more information on these operations). However, these may not always be successful and you may be advised to have an amputation below the knee. Around one-third of people with CLI will require an amputation.

CLI is an extremely serious complication that can be challenging to treat. Around one in four people will die from a complication of CLI, such as infection.
Heart attack and stroke

The build up of fat in the arteries in the legs that causes PAD can also affect other areas of your body too, such as the arteries supplying the heart and brain.

Blockages in these arteries can cause a heart attack or a stroke
Preventing peripheral arterial disease

The most effective way to prevent peripheral arterial disease (PAD) or stop your symptoms of PAD worsening is to tackle the build up of fat in your arteries (atherosclerosis).

There are five main ways you can achieve this:
Stop smoking
Eat a healthy diet
Take regular exercise
Lose weight (if you are overweight or obese)
Moderate your consumption of alcohol

These lifestyle changes are discussed in more detail below.
Smoking

If you smoke, it is strongly recommended you quit as soon as possible. T

It is recommended you use an anti-smoking treatment such as nicotine replacement therapy (NRT) or bupropion (a medication used to reduce cravings for cigarettes). People who use these treatments have a much greater success rate in permanently quitting than people who try to quit using willpower alone.

It is recommended you eat two to four portions of oily fish a week. Oily fish contains a type of fatty acid called omega-3, which can help lower your cholesterol levels.

Good sources of omega-3 include:
Herrings
Sardines
Mackerel
Salmon
Trout
Tuna

If you are unable or unwilling to eat oily fish, Dr B C Shah may recommend you take an omega-3 food supplement. However, never take a food supplement without first consulting Dr B C Shah. Some supplements, such as beta-carotene, can be harmful.

It is also recommended you eat a Mediterranean-style diet. This means you should eat more bread, fruit, vegetables and fish and less meat. Replace butter and cheese with products that are vegetable and plant-oil based, such as olive oil.
Weight management

If you are overweight or obese, aim to lose weight and maintain a healthy weight by using a combination of regular exercise and a calorie-controlled diet.
Alcohol

If you drink alcohol, do not exceed recommended daily limits (three to four units a day for men and two to three units a day for women).

A unit of alcohol is roughly half a pint of normal-strength lager, a small glass of wine or a single measure (25ml) of spirits. Regularly exceeding recommended alcohol limits will raise your blood pressure and cholesterol level, which will increase the risk of your PAD symptoms worsening and increase your risk of developing another more serious type of cardiovascular disease.

Contact Dr. B C Shah if you find it difficult to moderate your drinking. Counselling services and medication can help you reduce your alcohol intake.
Regular exercise

If you do not have PAD, then a minimum of 150 minutes of vigorous exercise a week is recommended. The exercise should be strenuous enough to leave your heart beating faster, and you should feel slightly out of breath afterwards.

Activities that you could incorporate into your exercise program include:
Brisk walking
Hill climbing
Running
Cycling
Swimming

If you find it difficult to achieve 150 minutes of exercise a week, start at a level you feel comfortable with. For example, you could do 5–10 minutes of light exercise a day and then gradually increase the duration and intensity of your activity as your fitness begins to improve.


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Feb16
Coronary angioplasty
Introduction
A coronary angioplasty is a procedure used to widen blocked or narrowed coronary arteries.
A short wire-mesh tube, called a stent, is inserted into an artery to allow blood to flow more freely through it.
Coronary angioplasty is sometimes known as percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI).
Why is a coronary angioplasty necessary?
Like all organs in the body, the heart needs a constant supply of blood. This is supplied by two large blood vessels called the left and right coronary arteries. In older people, these arteries can become narrowed and hardened. This is known as atherosclerosis.
Hardening of the coronary arteries can restrict the flow of blood to the heart, which can lead to angina.
The most common symptom of angina is chest pain, which is usually triggered by physical activity. While many cases of angina can be treated with medication, a coronary angioplasty may be required to restore the blood supply to the heart in severe angina.
Coronary angioplasties are also often used as an emergency treatment after a heart attack.
What are the benefits of a coronary angioplasty?
If you have angina, an angioplasty can:
Relieve your pain
Reduce your need for angina medication
Ease symptoms such as breathlessness
Enable you to be more active
Improve your ability to do everyday activities, such as climbing stairs and walking any distance
Make you feel generally better so you're more able to do the things you want to do, such as going to work and enjoying a social life
If you've had a heart attack, an angioplasty can:
Increase your chances of surviving by one-third more than clot-busting treatment (thrombolysis) can
Reduce your chances of having another heart attack
How is it performed?
You may have a pre-assessment of your health a few days before the operation. This may involve blood tests and a general health check. Being as fit as you can be before the procedure can help your recovery from a coronary angioplasty.
During an angioplasty, a flexible tube called a catheter is used to insert a mesh tube, known as a stent, into the coronary artery.
A small balloon is inflated to open the stent, which pushes against the artery walls. This widens the artery, squashing fatty deposits against the artery wall so that blood can flow through it more freely.
The procedure usually takes around 30 minutes, but it can take longer depending on how many sections of your artery need treatment. You will normally be able to go home the day after a coronary angioplasty. You will need to avoid driving for around a week.
How safe is a coronary angioplasty?
A coronary angioplasty is one of the most common types of treatment for the heart. Coronary angioplasties are most commonly performed in people who are 65 years of age or older as they are more likely to have angina.
A coronary angioplasty does not involve making major incisions in the body and is usually carried out safely in most people. Doctors refer to this as a minimally invasive form of treatment.
The risk of complications from a coronary angioplasty varies depending on individual circumstances. The risk increases slightly with age and if you have certain conditions. If you have an unrelated serious health condition, such as canceror liver failure, the risks of treatment may outweigh the benefits.
Are there any alternatives?
A coronary angioplasty may not be technically possible if your arteries are different from normal, for example if there are too many narrow sections.
In this circumstance, an alternative surgical procedure, known as a coronary artery bypass graft (CABG), may be considered.
Why do I need a coronary angioplasty?
A coronary angioplasty is necessary when hardening and narrowing of the coronary arteries prevents the heart from getting enough blood to function normally.
Atherosclerosis
Hardening of the arteries is known as atherosclerosis. Your arteries harden and narrow naturally as you get older, but this process can be dangerously sped up by:
Eating a high-fat diet
Smoking
Having high blood pressure (hypertension)
Having diabetes
Your ethnicity (where you were born and your cultural background)
For reasons that are not fully understood, high blood pressure and atherosclerosis are more common among people of African-Caribbean and south Asian (Indian, Pakistani, Bangladeshi and Sri Lankan) origin.
Angina
Once the hardening and narrowing of your coronary arteries reaches a certain point, your heart no longer receives the blood supply it needs to work properly. This can trigger the symptoms of angina, including:
Pain or discomfort in your chest
Breathlessness
When the symptoms of angina start, it is sometimes called an angina attack.
There are two types of angina:
Stable angina, where symptoms only last a few minutes, are triggered by physical activity and can be relieved with medication
Unstable angina, where symptoms develop even when you are resting, last longer than five minutes and cannot usually be relieved with medication
If your symptoms do not respond to angina medication, a coronary angioplasty may be recommended.
Heart attack
A coronary angioplasty can be used as an emergency treatment for a heart attack if the heart attack was caused by an interruption to your heart’s blood supply.How a coronary angioplasty is performed
You may have a pre-assessment of your health a few days before the operation. This will give you an opportunity to discuss any concerns with your Dr. B C Shah.
Before a coronary angioplasty is carried out, the arteries near your heart need to be assessed to make sure the operation is technically possible. This is done using a test called coronary angiography.
During coronary angiography, a long, flexible plastic tube called a catheter (about the width of the lead in a pencil) is inserted into a blood vessel, either in your groin or arm.
The tip of the catheter is guided using an X-ray to your heart or the arteries that supply your heart. A special fluid that shows up on X-rays, known as contrast medium, is injected through the catheter. The resulting pictures are called angiograms.
You may be asked not to eat or drink anything for four hours before a coronary angioplasty. You will usually be able to take most medications as normal up to the day of the procedure, with the exception of blood-thinning medication (anticoagulants), such as warfarin. You may also need to alter the timing of any diabetes medication you take.
The operation
A coronary angioplasty usually takes place in a room called a catheterisation laboratory, rather than in an operating theatre. A catheterisation laboratory is a room that is fitted with X-ray video to allow the doctor to monitor the procedure on a screen.
Coronary angioplasty usually takes about 30 minutes, although it may take longer depending on how many sections of your artery need to be treated.
You will be asked to lie on your back on an X-ray table. You will be linked up to a heart monitor and given a local anaesthetic to numb your skin. An intravenous (IV) line will also be inserted into a vein, in case you need to have painkillers or a sedative.
Dr. B C Shah will make a small incision in the skin of your groin or wrist and will insert a catheter. He will guide the catheter through the artery in your groin or arm, passing it through the main artery in your body (the aorta) and into the opening of your left or right coronary artery.
A thin, flexible wire is then passed down the inside of the blood vessel being treated to beyond the narrowed area. A small, sausage-shaped balloon is passed over the wire to the narrowed area and inflated for up to 60 seconds. This squashes the fatty material on the inside walls of the artery to widen it. This may be done several times.
While the balloon is inflated, the artery will be completely blocked and you may have some chest pain. However, this is normal and is nothing to worry about. The pain should go away when the balloon is deflated. Ask your cardiologist for pain medication if you find it uncomfortable.
You should not feel anything else as the catheter moves through the artery, but you may feel an occasional missed or extra heartbeat. This is nothing to worry about and is completely normal.
If you are having a stent inserted (see below), it will open up as the balloon is inflated and will be left inside your artery.
When the operation is finished, the cardiologist will check that your artery is wide enough to allow blood to flow through more easily. This is done by monitoring a small amount of contrast dye as it flows through the artery.
The balloon, wire and catheter are then removed and any bleeding is stopped with a dissolvable plug or firm pressure.
Going home
A coronary angioplasty often involves an overnight stay in hospital, but many people can go home on the same day if the procedure is straightforward. After the operation, you will not be able to drive for one week so you will need to arrange for someone to drive you home from hospital.
What type of stent?
A stent is a short, wire-mesh tube that acts like a scaffold to help keep your artery open. There are two main types of stent:
Bare metal (uncoated) stent
Drug-eluting stent, which is coated with medication that reduces the risk of the artery becoming blocked again
The biggest drawback of using bare metal stents is that, in around 30% of cases, the arteries begin to narrow again. This is because the immune system sees the stent as a foreign body and attacks it, causing swelling and excessive tissue growth around the stent.
Many cardiologists avoid this problem by using drug-eluting stents. These are coated with medication that reduces the body’s abnormal response and tissue growth.
Once the stent is in place, the medication is released over time into the area that is most likely to become blocked again. The two most researched types of medication are:
"-limus" drugs (such as sirolimus, everolimus and zotarolimus), which have previously been used to prevent rejection in organ transplants
paclitaxel, which inhibits cell growth and is commonly used in cancer chemotherapy
The use of drug-eluting stents has reduced the rate of arteries re-narrowing from around 30% to below 10%. However, as drug-eluting stents are still a relatively new technology, it is uncertain how effective or safe they are in the long term.
Before your procedure, discuss the benefits and risks of each type of stent with your cardiologist.
If you have a stent, you’ll also need to take certain anti-platelet drugs to help reduce the risk of blood clots forming around the stent. These include:
Aspirin, taken every morning for life
Clopidogrel, taken for 11 or 12 months depending on whether you have had a bare metal or drug-eluting stent, or whether you have had a heart attack
Prasugrel, which is used as an alternative to clopidogrel in some hospital
Recovering from a coronary angioplasty
You will normally be able to leave hospital the day after a coronary angioplasty. Arrange for a friend or family member to take you home.
Before you leave hospital, you should be told about any medication you need to take. You may also be given advice on improving your diet and lifestyle. You will be given a date for a follow-up appointment to check on your progress.
You may have a bruise under the skin where the catheter was inserted. This is not serious, but it may be sore for a few days. Occasionally, the wound can become infected. Keep an eye on it to check that it's healing properly. Tell Dr. B C Shah if it becomes red and sore.
Returning home
After having a coronary angioplasty, avoid doing any heavy lifting for about a week or until the wound has healed.
Do not drive for a week after the operation. If you drive a heavy vehicle for a living, such as a lorry or a bus, you must inform Dr. B C Shah that you have had a coronary angioplasty. He will arrange further testing before you can return to work. You should be able to drive again as long as:
You meet the requirements of an exercise/function test
You do not have another disqualifying health condition
If you have had a planned coronary angioplasty, you should be able to resume your normal activities within a week. However, if you have had an emergency angioplasty following a heart attack, it may be several weeks or months before you recover fully.
Sex
If your sex life was previously affected by angina, you may be able to have a more active sex life as soon as you feel ready after a coronary angioplasty. If you have any concerns, speak to Dr. B C Shah. According to experts, having sex is the equivalent of climbing a couple of flights of stairs in terms of the strain that it puts on your heart.
Further treatment
Most people need to take blood-thinning medications for up to one year after having an angioplasty. This is usually a combination of low-dose aspirin and a medication called clopidogrel. It is very important to follow your medication schedule as stopping medication early greatly increases the risk of the stent becoming blocked suddenly and causing a heart attack.
Clopidogrel blocks one of the chemicals that the body uses to trigger blood clotting.
Side effects of clopidogrel include:
diarrhoea
indigestion
abdominal pain
excessive or unusual bleeding, such as bleeding when injected, nosebleeds or blood in your urine (the loss of blood is usually minimal and nothing to worry about)
skin that may bruise more easily
Because of the side effect of excessive bleeding, men may prefer to shave with an electric razor.
The course of clopidogrel will be withdrawn after the agreed period, but most people need to continue taking low-dose aspirin for the rest of their life.
You may need to have another angioplasty if your artery becomes blocked again and your angina symptoms return. Alternatively, you may need a coronary artery bypass graft(CABG).
Risks of coronary angioplasty
As with all surgery, coronary angioplasty carries a risk of complications. Several factors increase your risk of experiencing these complications.
Who's at risk?
Factors that increase your chance of having complications include:
Your age – the older you are, the higher the risk. For example, a 60-year-old man with no other risk factors has a less than 1% risk of developing complications, while an 80-year-old has a 3% risk.
Whether the surgery was planned for angina or emergency treatment after a heart attack – emergency surgery is always riskier because there is less time to plan it.
Whether you have kidney disease – the intravenous dye used during an angioplasty can occasionally cause further damage to your kidneys.
Whether more than one coronary artery has become blocked – this is known as multi-vessel disease.
Whether you have a history of serious heart disease – this could include heart failure.
Dr. B C Shah can give you more information about your individual circumstances and level of risk.
Complications
Complications that can occur after an angioplasty include:
a heart attack, which is estimated to occur in 1 in 100 cases
a stroke, which is estimated to occur in 1 in 200 cases
excessive bleeding after the operation, which is estimated to occur in 1 in 200 cases and requires a blood transfusion
death, which is estimated to occur in 1 in 500 cases
Other heart surgery options
The most widely used surgical alternative to a coronary angioplasty is a coronary artery bypass graft (CABG).
Coronary artery bypass graft
A coronary artery bypass graft (CABG) is surgery to bypass a blockage in an artery. This is done using segments of healthy blood vessel, called grafts, taken from other parts of the body. Segments of vein from your legs or chest are used to create a new channel through which blood can be directed past the blocked part of the artery. This allows more blood to get through into the heart muscle.
Complications of CABG are uncommon, but are potentially serious. They include:
A heart attack, which is estimated to occur in 1 in 50 cases
A stroke, which is estimated to occur in 1 in 50 cases
You may not always be able to choose between having a coronary angioplasty or a CABG.
A CABG is usually recommended when multiple coronary arteries have become blocked and narrowed. However, it is invasive surgery so may not be suitable for people who are particularly frail and in poor health.
A coronary angioplasty may not be possible if the anatomy of the blood vessels near your heart is abnormal.
Coronary angioplasty or CABG?
If you can choose between having a coronary angioplasty or a CABG, be aware of the advantages and disadvantages of each technique.
As a coronary angioplasty is minimally invasive, you will recover from the effects of the operation quicker than you will from a CABG. The procedure also has a lower complication rate, but research has shown that up to one person in four who has a coronary angioplasty requires further treatment because the widened artery narrows again.
However, in the future, the number of people who need further surgery will probably fall sharply because of the use of drug-eluting stents.
CABG has a longer recovery time than coronary angioplasty and a higher complication rate. However, only 1 person in 10 who has a CABG requires further treatment. Also, research published in 2009 found that CABG is usually a more effective treatment option for people who are over 65 years of age and for people with diabetes.
Discuss the benefits and risks of both types of surgery with your surgical team.
Percutaneous transluminal coronary rotational atherectomy (PTCRA)
Percutaneous transluminal coronary rotational atherectomy (PTCRA) is a similar technique to coronary angioplasty. However, rather than using a balloon and a stent to expand the artery, a small diamond cutter is first used to remove the fatty deposit that is blocking the artery
It is usually used when the coronary artery has a high level of calcium in it. Calcium makes the artery very hard and can prevent balloons or stents expanding properly to relieve the narrowing. Once the small diamond cutter has been used, the artery is then treated with balloons and stents as normal.
Evidence has found that PTCRA is no more effective than a coronary angioplasty, so it is usually only carried out in people who are not suitable for conventional coronary angioplasty.


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Feb15
Chickenpox
Introduction
Chickenpox is a mild and common childhood illness that most children catch at some point.
It causes a rash of red, itchy spots that turn into fluid-filled blisters. They then crust over to form scabs, which eventually drop off.
Some children have only a few spots, but in others they can cover the entire body. The spots are most likely to appear on the face, ears and scalp, under the arms, on the chest and belly and on the arms and legs.
Chickenpox (medically known as varicella) is caused by a virus called the varicella-zoster virus. It's spread quickly and easily through the coughs and sneezes of someone who is infected.
Chickenpox is most common in children under 10. In fact, chickenpox is so common in childhood that 90% of adults are immune to the condition because they've had it before.
Children usually catch chickenpox in winter and spring, particularly between March and May.
What to do
To prevent spreading the infection, keep children off nursery or school until all the spots have crusted over.
Chickenpox is most infectious from one to two days before the rash starts, until all the blisters have crusted over (usually five to six days after the start of the rash).
If your child has chickenpox, try to keep them away from public areas to avoid contact with people who have not had it, especially people who are at risk of serious problems, such as newborn babies, pregnant women and anyone with a weakened immune system (for example, people having cancer treatment or taking steroid tablets).
Chickenpox treatment
Chickenpox in children is considered a mild illness, but expect your child to feel pretty miserable and irritable while they have it.
Your child is likely to have a fever at least for the first few days of the illness. The spots can be incredibly itchy.
There is no specific treatment for chickenpox, but there are pharmacy remedies which can alleviate symptoms, such as paracetamol to relieve fever and calamine lotion and cooling gels to ease itching.
In most children, the blisters crust up and fall off naturally within one to two weeks.
When to see Dr. B C Shah
For most children, chickenpox is a mild illness that gets better on its own.
But some children can become more seriously ill with chickenpox. They need to see a doctor.
Contact Dr. B C Shah straight away if your child develops any abnormal symptoms, for example:
If the blisters on their skin become infected
If your child has a pain in their chest or has difficulty breathing
Chickenpox in adults
Chickenpox may be a childhood illness, but adults can get it too. Chickenpox tends to be more severe in adults than children, and adults have a higher risk of developing complications.
As with children, adults with chickenpox should stay off work until all the spots have crusted over. They should seek medical advice if they develop any abnormal symptoms, such as infected blisters.
Adults with chickenpox may benefit from taking antiviral medicine if treatment is started early in the course of the illness.
Who's at special risk?
Some children and adults are at special risk of serious problems if they catch chickenpox. They include:
Pregnant women
Newborn babies
People with a weakened immune system
These people should seek medical advice as soon as they are exposed to the chickenpox virus or they develop chickenpox symptoms.
They may need a blood test to check if they are immune (protected from) chickenpox..
Chickenpox in pregnancy
Chickenpox occurs in approximately three in every 1,000 pregnancies. It can cause serious complications for both the pregnant woman and her baby.
Chickenpox and shingles
One you have had chickenpox, you usually develop antibodies to the infection and become immune to catching it again. However, the virus that causes chickenpox, the varicella virus, remains dormant (inactive) in your body's nerve tissues and can return later in life as an illness called shingles.
It is possible to catch chickenpox from someone with shingles, but not the other way around.
Is there a vaccine against chickenpox?
There is a chickenpox vaccine but it is not part of the routine childhood vaccination schedule. The vaccine is only offered to children and adults who are particularly vulnerable to chickenpox complications.
Symptoms of chickenpox
The most commonly recognised chickenpox symptom is a red rash that can cover the entire body.
However, even before the rash appears, you or your child may have some mild flu-like symptoms including:
Feeling sick
A high temperature (fever) of 38ºC (100.4ºF) or over
Aching, painful muscles
Headache
Generally feeling unwell
Loss of appetite
These flu-like symptoms, especially the fever, tend to be worse in adults than in children.
Chickenpox spots
Soon after the flu-like symptoms, an itchy rash appears. Some children and adults may only have a few spots, but others are covered from head to toe.
The spots normally appear in clusters and tend to be:
Behind the ears
On the face
Over the scalp
Under the arms
On the chest and belly
On the arms and legs
But the spots can be anywhere on the body, even inside the ears and mouth, on the palms of the hands, soles of the feet and inside the nappy area.
Although the rash starts as small, itchy red spots, after about 12-14 hours the spots develop a blister on top and become intensely itchy.
After a day or two, the fluid in the blisters gets cloudy and they begin to dry out and crust over.
After one to two weeks, the crusting skin will fall off naturally.
New spots can keep appearing in waves for three to five days after the rash begins. Therefore different clusters of spots may be at different stages of blistering or drying out.
Unusual symptoms
Most healthy children (and adults) recover from chickenpox with no lasting ill-effects simply by resting, just as with a cold or flu.
But some children and adults are unlucky and have a more severe bout than usual.
Contact Dr. B C Shah straight away if you or your child develop any abnormal symptoms, for example:
If the skin surrounding the blisters becomes red and painful
If you or your child start to get pain in the chest or have difficulty breathing
In these cases, prescription medicine, and possibly hospital treatment, may be needed.
Causes of chickenpox
Chickenpox is caused by the varicella-zoster virus. You catch it by coming into contact with someone who is infected with the virus.
It's a very contagious infection. About 90% of people who have not previously had chickenpox will become infected when they come into contact with the virus.
How you catch the virus
The chickenpox virus is spread in the same ways as colds as flu. It's contained in the millions of tiny droplets that come out of the nose and mouth when an infected person sneezes or coughs. You can then become infected with the virus by breathing in these droplets from the air.
You can also become infected by handling a surface or object that these droplets have landed on, then transferring the virus to yourself by touching your face.
It takes seven to 21 days for the symptoms of chickenpox to show after you have come into contact with the virus. This is called the ‘incubation period’.
Someone with chickenpox is most infectious from one to two days before the rash appears until all the blisters have crusted over. This usually takes five to six days from the start of the rash.
Shingles
If you have not had chickenpox before, you can also catch chickenpox from someone with shingles (an infection caused by the same virus). However, it's not possible to catch shingles from someone who has chickenpox.
Diagnosing chickenpox
You or your child should not usually need any medical tests to diagnose chickenpox. You can be pretty sure that it is chickenpox if there are the key symptoms of a mild fever followed by an itchy rash, blisters and scabs.
Chickenpox spots are usually distinctive enough to distinguish from other rashes, although occasionally they can be easily confused with other conditions that affect the skin, such as insect bites or scabies (a contagious skin condition that causes intense itching).
If you're still uncertain about what is causing the symptoms, Dr. B C Shahcan carry out a simple blood test to identify the virus.
When to contact Dr. B C Shah
1. See Dr. B C Shah if you're not sure whether you or your child have chickenpox.
2. Contact Dr. B C Shah urgently if you have been in contact with someone who has chickenpox or you have chickenpox symptoms and:
You are pregnant
You have a weakened immune system (the body’s defence system)
Your baby is less than four weeks old
Chickenpox in these instances can cause serious complications if left untreated. It is essential to seek medical advice so that you can receive any necessary treatment.
3. Contact Dr. B C Shah if you have chickenpox and are breastfeeding. They can advise about whether you should continue breastfeeding your baby.
Having a blood test
Once you have contacted Dr. B C Shah, you may need a test to see if you're already immune from chickenpox.
If you have had chickenpox in the past, then it is extremely unlikely that you will develop chickenpox for a second time. If you've never had chickenpox, or you're unsure whether you've had it, then you may need an immunity test.
This is a blood test that checks whether you are producing the antibodies to the chickenpox virus.
If your blood test result shows that you have the antibodies, you'll be naturally protected from the virus.
Treating chickenpox
There is no cure for chickenpox, and the virus usually clears up by itself without any treatment.
However, there are ways of easing the itch and discomfort, and there are important steps you can take to stop chickenpox spreading.
Painkillers
If your child is in pain or has a fever (high temperature), you can give them a mild painkiller, such as paracetamol. Paracetamol is available over-the-counter in pharmacies. Always read the manufacturer's dosage instructions.
You should avoid giving your child ibuprofen if they have chickenpox. This is because there have been some cases where using ibuprofen and other non-steroidal anti-inflammatory drugs(NSAIDs) has caused serious skin infections.
Ibuprofen should also be avoided if you or your child hasasthma, or a history of stomach problems, such as stomach ulcers.
If you're not sure whether ibuprofen is suitable, check with Dr. B C Shah. If your child is younger than three months old, always speak to Dr. B C Shah before you give your child any kind of pain relief.
If you're pregnant and need to take painkillers, then paracetamol is the first choice. You can use it at any stage of pregnancy. Only take ibuprofen during the second trimester (weeks 14-27 of the pregnancy).
If you're pregnant and you have chickenpox, you should visit Dr. B C Shah as soon as possible. You may need to have antiviral medicine or immunoglobulin treatment to prevent your symptoms from getting worse (see below).
Keeping hydrated
It is important for children (and adults) with chickenpox to drink plenty of water to avoid dehydration. Sugar-free ice-lollies are a good way of getting fluids into children. They also help to soothe a sore mouth that has chickenpox spots in it.
Avoid any food that may make the mouth sore, such as salty foods. Soup is easy to swallow as long as it is not too hot.
Stop the scratching
Chickenpox can be incredibly itchy, but it's important for children (and adults) to not scratch the spots so as to avoid future scarring.
One way of stopping scratching is to keep fingernails clean and short. You can also put socks over your child's hands at night to stop them scratching the rash as they sleep.
If your child's skin is very itchy or sore, try using calamine lotion or cooling gels. These are available in pharmacies and are very safe to use. They have a soothing, cooling effect.
A stronger medicine called chlorphenamine can also help to relieve the itching. It's available from your pharmacist over the counter or it can be prescribed by Dr. B C Shah. Chlorphenamine is taken by mouth and is suitable for children over one year old.
Cool clothing
If your child has a fever, or if their skin is sore and aggravated, dress them appropriately so that they don't get too hot or too cold. Loose-fitting, smooth, cotton fabrics are best and will help stop the skin from becoming sore and irritated.
If your child has chickenpox, avoid sponging them down with cool water. This can make your child too cold, and it may make them shiver.
Stronger treatments
Antiviral medicine
Aciclovir is an antiviral medicine that is sometimes given to people with chickenpox.
Aciclovir may be prescribed to:
Pregnant women
Adults, if they visit Dr. B C Shah within 24 hours of the rash appearing
Newborn babies
People with a weakened immune system (the body’s defence system)
Ideally, aciclovir needs to be started within 24 hours of the rash appearing. It does not cure chickenpox, but it makes the symptoms less severe. You normally need to take the medicine as tablets five times a day for seven days.
If you are taking aciclovir, make sure you drink plenty of fluids. Side effects are rare but can include nausea and diarrhoea.
Immunoglobulin treatment
Immunoglobulin is a solution of antibodies that is taken from healthy donors. Varicella-zoster immunoglobulin (VZIG) contains antibodies to the chickenpox virus.
Immunoglobulin treatment is given by drip. It is not used to treat chickenpox but to protect people who are at high risk of developing a severe chickenpox infection. This includes:
Pregnant women
Newborn babies
People with weakened immune systems
In the case of pregnant women, immunoglobulin treatment also reduces the risk of the unborn baby becoming infected.
As the supply of VZIG is limited, it will only be considered if a high-risk person has:
Been significantly exposed to the virus – significant exposure could be face-to-face contact with someone who has chickenpox
Been in the same room for 15 minutes with someone who has chickenpox
Had a blood test to confirm that they've not had chickenpox before
In some cases, newborn babies may be given immunoglobulin treatment without having a blood test first.
Complications of chickenpox
Complications of chickenpox are rare in healthy children. The most common complication is where the blisters become infected with bacteria.
A sign that the blisters have become infected is when the surrounding skin becomes red and sore.
If you think that your child's blisters have become infected, contact Dr. B C Shah as the child may need a course of antibiotics.
The people who are most at risk of developing chickenpox complications are:
Adults
Pregnant women
Babies under four weeks old
People with a weakened immune system
Adults
Chickenpox can be more serious in adults than in children. Adults with the virus are more likely to be admitted into hospital. Approximately 5-14% of adults with chickenpox develop lung problems, such as pneumonia. If you smoke, your risk of developing lung problems is much greater.
Although it is more serious in adults, most people will still make a full recovery from the chickenpox virus.
Pregnant women
If you're pregnant, chickenpox can occasionally cause complications.
For example, your risk of developing pneumonia is slightly higher if you're pregnant, especially if you smoke. The further you are into your pregnancy, the more serious the risk of pneumonia tends to be.
If you get chickenpox while you're pregnant, there is also a small but significant risk to your unborn baby.
If you are infected with chickenpox during the first 20 weeks of your pregnancy, there is a risk that your unborn baby could develop a condition known as foetal varicella syndrome.
This syndrome is rare. The risk of it occurring in the first 12 weeks of pregnancy is less than 1%. Between 13 and 20 weeks, the risk is 2%.
Foetal varicella syndrome can cause serious complications, including:
Scarring
Eye defects, such as cataracts
Shortened limbs
Brain damage
There have been reports of damage to the unborn baby from foetal varicella syndrome when a pregnant woman catches chickenpox after week 20. But the risk at this late stage in pregnancy is thought to be much less than 1%.
However, there are other risks from catching chickenpox after week 20 of pregnancy.
It is possible that your baby may be born prematurely (before week 37 of the pregnancy).
And if you are infected with chickenpox seven days before or seven days after giving birth, your newborn baby may develop a more serious type of chickenpox. In a few severe cases, this type of chickenpox can be fatal.
See Dr. B C Shah urgently if you're pregnant or have given birth in the last seven days and you think you may have chickenpox, or if you've been exposed to someone who has chickenpox.
People with a weakened immune system
Your immune system is your body's way of defending itself against disease, bacteria and viruses.
If your immune system is weak or does not work properly, you are more susceptible to developing infections such as chickenpox. This is because your body produces fewer antibodies to fight off the infection.
You may have a weakened immune system if you take immunosuppressive medication. This is medicine that works by damping down your immune system.
Immunosuppressive medication such as steroid tablets may be used if, for example, you have an inflammatory condition such as rheumatoid arthritis, lupus or certain blood conditions.
If you have a weakened immune system, you're also more at risk of developing complications from chickenpox. These complications include:
pneumonia
septicaemia (blood poisoning)
meningitis
See Dr. B C Shah urgently if you have a weakened immune system and you've been exposed to the chickenpox virus.
Preventing the spread of chickenpox
If your child has chickenpox, inform their school or nursery and keep them at home while they are infectious, which is until the last blister has burst and crusted over. This usually takes five or six days after the rash begins.
If you have chickenpox, stay off work and at home until you're no longer infectious.
If either you or your child has chickenpox, it is also a good idea for you, or them, to avoid contact with:
Pregnant women
Newborn babies
Anyone who has a weak immune system, such as people who are having chemotherapy (a treatment for cancer) or taking steroid tablets
If you or your child have recently been exposed to the chickenpox virus, you may not be able to visit friends or relatives in hospital. Telephone the ward to check first.
Travelling on a plane
If you or your child have chickenpox, you may not be allowed to fly until six days after the last spot has appeared.
You and your child should be safe to fly once you're past the infectious stage and all of the blisters have crusted over. But it's best to check the policy of your airline first. Inform the airline as soon as chickenpox is diagnosed.
It is also important to let your travel insurer know if you or your child have chickenpox. You need to make sure that you'll be covered if you have to delay or cancel your holiday, or if you need to extend your stay until your child is well enough to fly home.
Stop the virus spreading
Chickenpox can sometimes be spread through contact with objects that have been infected with the virus, such as children's toys, bedding or clothing.
If someone in your household has chickenpox, you can help stop the virus spreading by wiping any objects or surfaces with a sterilising solution and making sure that any infected clothing or bedding is washed regularly.
Vaccination
There is a chickenpox vaccine that is used to protect people who are most at risk of a serious chickenpox infection or of passing the infection on to someone who is at risk.
People who may be considered for chickenpox vaccination include:
healthcare workers who are not already immune – for example, a nurse who has never had chickenpox and who may pass it to someone they are treating if they become infected
people living with someone who has a weakened immune system – for example, the child of a parent receiving chemotherapy
The vaccine is not suitable for pregnant women. Avoid getting pregnant for three months after having the vaccine. The vaccine is also not suitable for people with weakened immune systems.


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Feb15
OUR GOAL: DR. SHRINIWAS KASHALIKAR
OUR GOAL: DR. SHRINIWAS KASHALIKAR

One of the doubts about the practice of NAMASMARAN (JAP, JAAP, JIKRA, SUMIRAN and SIMARAN i.e. remembering and/or reciting the name [NAMA] of God); is; How can we practice NAMASMARAN; when we are involved in intellectual work (and not merely physical)?
The answer is; as follows.
Self realization; is actually a process of nullifying our subjectivity or individuality; and being one with our core! This is a tricky process! If we try to nullify our subjectivity arbitrarily; then we tend lose our core; and become listless losers. If we try to catch hold of our core voluntarily; then we usually land up in bloated ego and maniacal behavior. Thus through ‘our’ efforts; we tend be entangled in; depression and melancholy or maniacal obsession; irrespective of; or at the cost of others!
In both cases we remain far away from our SELF.
NAMASMARAN; begun with a practice of 5 minutes per day; even if it is without any understanding; gradually reduces the time; of our intellectual, emotional and instinctual involvement; in pettiness and superficiality; and transforms our individualistic (and fragmented and sectarian) perspective, thinking, feelings and instincts; into holistic or objective. This marks our ascent towards our SELF i.e. being one with our core.
In the course of time; as we ascend up; the glimpses of our immortality; begin to expose the redundancy of all our activities; including our intellectual efforts! Gradually the proportion of personal pleasures, entertainments, profiteering and intellectual engagements; and the practice of NAMASMARAN reverses.
NAMASMARAN becomes a major activity! We begin to be restless; without NAMASMARAN. We being to feel secure and comfortable in NAMASMARAN and be a part of universally benevolent spiritual dynamism!
At this point we begin to understand; why our guru preached NAMASMARAN; with so much of intensity! We begin to realize; how and why our goal of life is; total and loving involvement in NAMASMARAN!


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