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Mar11
http://dx.doi.org/10.1016/j.jcot.2016.02.012
Case Report
Ipsilateral hip and knee dislocation: Case report and
review of literature
Gaurav Sharma MBBS, MS (Ortho)a, Deepak Chahar MBBS, MS (Ortho)b,
Ravi Sreenivasan MBBS, MS (Ortho), DNB (Ortho)b,
Nikhil Verma MBBS, MS (Ortho), DNB (Ortho)b,
Amite Pankaj MBBS, MS (Ortho), DNB (Ortho), MRCS (Edin)c,*
a Senior Resident, Department of Orthopaedics, AIIMS, Delhi, India
b Senior Resident, Department of Orthopedics, University College of Medical Sciences, University of Delhi and GTB
Hospital Delhi, India
c Professor, Department of Orthopedics, University College of Medical Sciences, University of Delhi and GTB Hospital
Delhi, India
1. Introduction
Hip or


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Mar24
Spleen Removal (Splenectomy)
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Posted in Disease Information

Spleen Removal (Splenectomy)


What is a splenectomy?

A splenectomy refers to taking out the spleen in surgery. Removing part of the spleen is called a partial splenectomy. Removing all of the spleen is called a total splenectomy.

What is a spleen?

The spleen is an organ that is located on the upper left side of the abdomen. About the size of a fist, the spleen is important because it helps fight infection in the body by filtering the blood. Another function is the storage of blood cells. The spleen keeps blood flowing to the liver.

Why would you need to have your spleen removed?

A splenectomy is recommended as a treatment for some conditions that cause hypersplenism and might be recommended as a treatment for others. Hypersplenism is not a disease itself, but is more of a syndrome, or a collection of symptoms. It means that the spleen has become overactive, enlarged, and is storing and destroying too many blood cells and platelets.

When is a splenectomy recommended?

There are two reasons that a spleen is always removed: to treat primary cancers of the spleen and to treat a disease called hereditary spherocytosis.

Hereditary spherocystosis (HS) is an inherited disease that involves the lack of ankyrin a specific protein, and the formation of abnormally-shaped red blood cells, called spherocytes. Spherocytes do not move as easily as they should and end up staying longer in the spleen. This almost always increases the size of the spleen. An enlarged spleen is called splenomegaly. The cells eventually become damaged and results in anemia and jaundice. Children with HS are given folic acid supplements on a daily basis. The spleen is removed after a child reaches the age of five.

Other conditions that are often treated with splenectomy

•Idiopathic thrombocytopenic purpura, a disease in which antibodies kill off platelets. The reason that the antibodies form is not known.
•Trauma, such as injury due to an auto accident
•Spleen with an abscess (collection of pus due to infection)
•Splenic artery rupture, possible during pregnancy
•Sickle cell disease (a blood disorder that is characterized by sickle-shaped, rather than disc-shaped, red blood cells)
•Thalassemia (inherited blood disorder resulting in inadequate hemoglobin production)
How are spleen disorders diagnosed?

•Blood tests
•Physical examination (an enlarged spleen may be felt by Dr. B C Shah)
•Imaging tests such as ultrasounds, X-rays, magnetic resonance imaging (MRI), or computerized tomography (CT) scans
•Bone marrow tissue biopsy
Removal of spleen tissue is not advisable due to the possibility of excessive bleeding.

How are spleens removed?

In most cases, splenectomies can be performed as laparoscopic surgeries if the spleen is not too enlarged. Using this technique, a tube is inserted into the abdomen and the space inflated with carbon dioxide. Dr. B C Shah will place other tubes into the abdomen through other small holes, allowing the placement of instruments. The spleen is cut free of all of connections, put inside a special bag and pulled through one of the largest holes in the abdomen.

If the spleen is too large for laparoscopic removal, the spleen will be taken out in an "open" procedure with a single larger incision. In addition to spleen size, Dr. B C Shah fmight opt for an open procedure if there is a lot of scar tissue from previous procedures, if there is an ability to see clearly enough to perform laparoscopy, or if there are bleeding problems. This decision may be made prior to or during surgery.

What are the possible complications of splenectomy?

Possible complications include the usual risks of all surgeries, including infection. There is also a risk of pneumonia or pancreatitis (inflammation of the pancreas). Immediately after the surgery, the patient is likely to be put on medications to prevent infection.

After having a splenectomy, the patient must always be extra careful about infections. Dr. B C Shah is likely to have immunized the patient before surgery. Other likely recommendations include:

•Have a pneumonia vaccine about every five years.
•Have yearly flu shots.
•A child who has had his or her spleen removed may be put on antibiotics for two to several years after the surgery, possibly until adulthood.
•Contact Dr. B C Shah immediately if you have a fever or other indications of infection.
•Avoid travel to places where you could contract malaria.


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Mar23
It is not always Piles or Fissures!
A 19 yr boy studying in college came with complaints of constipation, bleeding & pain while defecating since 3 months. He had consulted many nearby family physicians. They told him that it was a piles problem and they had given him different types of oral laxatives and local ointments. However, unfortunately none of them had ever examined him. He was even advised piles surgery. He latter consulted an Ayurvedic doctor, who examined him & said that it was not piles but anal fissure. He carried out a minor surgery for same in his clinic. The patient has no relief and his bleeding & pain did not subside. Feeling frustrated at last he came to Bhaktivedanta hospital. Details of patient were noted & a proper rectal examination was performed. He had no piles or fissure. On examination it was found that he had a large tumor which would bleed on touching. The provisional clinical diagnosis was "Cancer of rectum" He was asked to undergo a Colonoscopy and CT scan. The diagnosis was confirmed. The patient was nicely counselled and was advised further treatment in the form of surgery.
Lesson: ALWAYS TAKE EXPERT OPINION FOR YOUR PROBLEMS. NEVER RELY ON G.P. FOR PROBLEMS PERSISTING BEYOND ONE WEEK OF TREATMENT.


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Feb14
Chemotherapy
Introduction
Chemotherapy is a type of treatment for cancer where medicine is used to kill cancer cells. It can be given either as a tablet, or as an injection or infusion directly into a vein.
Cancer
Cancer refers to a number of conditions where the body’s cells grow and reproduce uncontrollably. The rapid growth of cancerous cells is known as a malignant tumour. These cells can spread out of the tumour and into other parts of the body to form new tumours.
How chemotherapy is used
There are four main ways that chemotherapy can be used:
To try to cure cancer completely – this is known as curative chemotherapy
To help make other treatments more effective – for example, chemotherapy can be combined with radiotherapy (where radiation is used to kill cancerous cells), or it can be used before surgery
To relieve symptoms – a cure may not be possible for advanced cancer, but chemotherapy may be used to relieve the symptoms and slow the spread of the condition. This is known as palliative chemotherapy
To reduce the risk of the cancer returning after surgery or radiotherapy.
Side effects
Chemotherapy is a very effective cancer treatment and has helped save millions of lives. However, it does cause side effects.
The medications used in chemotherapy are not very good at telling the difference between fast-growing cancer cells and other types of fast-growing cells. These include blood cells, skin cells, the cells on the scalp and the cells inside the stomach.
This means that most chemotherapy medications have a poisonous effect on the body's cells. Common side effects include:
Feeling tired and weak all the time
Feeling sick
Being sick
Hair loss, although this can sometimes be prevented using a technique called a cold cap
Some people only have minimal side effects. However, for most people, a course of chemotherapy can be very unpleasant and upsetting.
In many cases, having chemotherapy will make you feel worse than the cancer you are being treated for.
Living with and adapting to the side effects of chemotherapy can be challenging. But it's important to realise that most, if not all, side effects will disappear once the treatment is complete.
Some people who are about to start chemotherapy are concerned that the harmful effects of chemotherapy can be passed to other people, particularly people who are vulnerable, such as children or pregnant women. However, there is no risk associated with coming into close contact with someone who is having chemotherapy.
How chemotherapy works
There are over 50 different types of chemotherapy medication which can be used to treat hundreds of different types of cancer.
However, they all work in one of the following two ways:
They stop cells from reproducing, which can be very useful in preventing the spread of cancer.
They essentially "trick" cells into self-destructing.
All human cells have a limited lifespan. They eventually die and are replaced by new cells. Chemotherapy medications make the cancer cells "think" that their lifespan has finished.
Depending on the type of cancer you have, you may be given:
Monotherapy – where only one chemotherapy medication is used
Combination therapy – where a combination of different medications is used
When is chemotherapy given?
Depending on the type and severity of your cancer, chemotherapy will be given at different stages of your treatment. You may receive chemotherapy:
Before having surgery to remove a tumour or radiotherapy to shrink it, so that other treatments can then begin (this is known as neo-adjuvant therapy)
In combination with radiotherapy, which is known as chemoradiation
After having surgery or radiotherapy, which is known as adjuvant therapy
Chemotherapy protocols
You will need to have regular chemotherapy over a set period of time for it to be effective.
Dr. B C Shah will draw up a treatment plan that gives details of how many sessions you will need, how long the course should last, and how much time should pass between each session. It is common for there to be a break after each session to allow your body to recover from the effects of the medication.
This treatment plan is known as a chemotherapy protocol. Chemotherapy protocols vary depending on the type of cancer you have and how advanced it is.
An example of a chemotherapy protocol is:
One day of treatment
Seven days of rest
One day of treatment
21 days of rest
This cycle will then be repeated six times over 18 weeks.
Who can use chemotherapy?
Delaying treatment or, in some cases, not having chemotherapy may be recommended if you:
Are in the first three months of pregnancy – using chemotherapy during this time has a very high risk of causing birth defects
Have low levels of blood cells – chemotherapy can lower your blood cell count more, so it could make you feel very ill and, in some cases, vulnerable to infection. Medication and sometimes a blood transfusion may be required to raise your blood cell count
Have severe kidney or liver disease – most chemotherapy medications are processed by your liver and kidneys, so this could have a very harmful effect if your liver and kidneys are already damaged
Have had recent surgery or a wound – chemotherapy can disrupt the body’s ability to heal wounds, so it's usually recommended that the wound heals before treatment begins
Have an ongoing infection – chemotherapy can make you more vulnerable to the effects of infection, increasing your risks of developing serious complications
As chemotherapy is a potentially life-saving treatment, it is usually recommended for most people with cancer, even if they are in poor health and the treatment is likely to make them feel worse.
How chemotherapy is performed
Dr. B C Shah
Many hospitals use multi-disciplinary teams (MDTs) to provide chemotherapy treatment.
MDTs are teams of specialists that work together. Members of your MDT may include a:
Medical oncologist – a specialist in the non-surgical treatment of cancer using techniques such as radiotherapy and chemotherapy
Pathologist – a specialist in diseased tissue
Haematologist – a blood specialist
Psychologist – who can provide support and advice about the psychological and emotional impact of chemotherapy
Clinical nurse specialist (CNS) – who will offer you support throughout your care, from diagnosis.
As well as having a specialist MDT, you may also be assigned a key worker (this is often the CNS). You will be given their details so that you can get in touch with your team at any point during your treatment. They will also be involved in coordinating your care.
Deciding what treatment is best for you can often be confusing. Dr. B C Shah will recommend what they think is the best treatment option, but the final decision will be yours.
Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask Dr. B C Shah.
For example, you may want to find out:
What the purpose of your chemotherapy is – for example, whether it's being used to cure your cancer, relieve your symptoms or make other treatments more effective
What side effects you're likely to experience and whether anything can be done to prevent or relieve them
How effective the chemotherapy is likely to be at curing your cancer or at least slowing it down
Whether any alternative treatments can be used instead of chemotherapy
Blood tests
Before chemotherapy begins, you will need to have a number of blood tests to assess your health and to make sure you can cope with any side effects.
Blood tests are useful for assessing the health of your liver and kidneys. This is important because chemotherapy medications will pass through your liver and kidneys, where they will be broken down. The medication can harm the liver. Therefore, if you have liver damage, it may not be suitable for you until your liver and kidneys have recovered.
Another important role of blood testing is to assess your blood count. This is a measurement of how many blood cells you have.
There are three types of blood cell:
Red blood cells – which carry oxygen around your body
White blood cells – which help fight infection
Platelets – which help the blood to clot (thicken)
Chemotherapy reduces the number of all three types of blood cells.
If you have a low blood count, treatment may be delayed until your blood count has returned to normal. Alternatively, medication can be used to raise your blood count. In some cases, a blood transfusion may be required.
You will have regular blood tests during your chemotherapy so that your liver, kidneys and blood count can be carefully monitored.
You may also need other tests to check how well the cancer is responding to treatment. The tests you require will depend on the type of cancer you have.
Types of chemotherapy
Chemotherapy is usually given in one of two ways:
as a tablet – which is known as oral chemotherapy
injected directly into a vein – which is known as intravenous chemotherapy
The type of chemotherapy you have will depend on the type of cancer and how advanced it is.
Oral chemotherapy
If you are in good health, you may be able to take your tablets at home. However, you will still need to go to hospital for regular check-ups.
It is very important that you only take your tablets on the days specified in your chemotherapy protocol. If you forget to take a tablet, contact Dr. B C Shah for advice. Also contact Dr. B C Shah if you are sick shortly after taking a tablet.
Intravenous chemotherapy
A number of different devices can be used to give chemotherapy medication into a vein.
The type of device used will often depend on the type of cancer you have and your general health. You may be able to choose which device you have, although this is not always possible.
Intravenous chemotherapy is not like having a vaccine, where you are given one quick injection. Instead, chemotherapy medications are slowly released into a vein over a period of time. The time it takes to give one dose can range from several hours to several days.
Occasionally, some people need a continuous low dose of chemotherapy medication over several weeks or months. If this is the case, you may be given a small portable pump that you can take home with you.
The devices used for intravenous chemotherapy are described below.
Cannula
A cannula is a small tube that is placed into a vein on the back of your hand or lower arm. Chemotherapy medication is slowly injected through the tube into your vein. Once the dose of medication has been delivered, the tube can be removed.
Skin-tunnelled catheter
A skin-tunnelled catheter is a fine tube that is inserted into your chest and connected to one of the veins near your heart. The catheter can be left in place for several weeks or months, so that you do not have to have repeated injections. The catheter can also be used to carry out blood tests.
Peripherally inserted central catheter
A peripherally inserted central catheter (PICC) is similar to a skin-tunnelled catheter except the tube is connected to your arm rather than your chest.
Implanted port
An implanted port is a chamber that can be inserted under your skin and connected to a nearby vein. A special needle is placed into the chamber and connected to a drip or used for blood tests.
Other medication
If you are having chemotherapy, check with Dr. B C Shah before you take any other medication, including over-the-counter (OTC) medicines and herbal remedies. Other medication could react unpredictably with your chemotherapy medication.
Pregnancy
You should avoid becoming pregnant while having chemotherapy. This is because many medications used in chemotherapy can cause birth defects.
You will need to use a barrier method of contraception, such as condoms, while having chemotherapy and for a year after your treatment has finished.
Contact Dr. B C Shah immediately if you think you may have become pregnant while having chemotherapy.
Side effects of chemotherapy
It is difficult to predict exactly what side effects you will experience while having chemotherapy. Different people react to treatment in different ways.
A small number of people have very few or even no side effects.
The common side effects of chemotherapy are listed below, although it is unlikely that you will experience them all.
Dr. B C Shah is there to help you cope with the physical and psychological side effects.
When to get urgent medical advice
While the side effects of chemotherapy can be distressing, most do not pose a serious threat to your health.
However, occasionally some side effects can be very serious. For example, if you have a rapid fall in white blood cells, you may be vulnerable to a serious infection.
People having chemotherapy for cancer that developed inside their blood cells or bone marrow are most at risk of serious infections. This is because this type of cancer will already have caused a reduction in white blood cell numbers.
Symptoms of serious infection include:
a high temperature of 38C (100.4F) or above
shivering
breathing difficulties
chest pain
flu-like symptoms, such as muscle aches and pain
bleeding gums or nose
bleeding from other parts of the body that does not stop after applying pressure for 10 minutes
mouth ulcers that stop you eating or drinking
vomiting that continues despite taking anti-sickness medication
four or more bowel movements a day, or diarrhoea
If you have any of these symptoms, contact Dr. B C Shah immediately.
Fatigue
Fatigue or tiredness is a common side effect of chemotherapy. Almost everyone who has chemotherapy will experience fatigue. You may feel generally tired or you may tire very easily after doing normal, everyday tasks.
While having chemotherapy, it is important to get plenty of rest. Do not carry out tasks or activities that you do not feel up to.
Light exercise, such as walking or yoga, can help boost your energy levels, but be careful not to push your body too hard.
If you are working, you may need to ask your employer to let you work part time until your chemotherapy has finished.
Contact your Dr. B C Shah if you are suddenly significantly more tired than usual and you also feel out of breath. Extreme fatigue and shortness of breath can be a sign of anaemia. This is a condition caused by having a low number of red blood cells.
Nausea and vomiting
Nausea (feeling sick) and vomiting (being sick) are common side effects of chemotherapy. They affect around half of all people being treated.
If you have nausea and vomiting, you will be given medication to help control your symptoms. This type of medication is known as an anti-emetic.
Anti-emetics can be given in a number of different ways, including:
as a tablet or capsule, which can either be swallowed or placed under your tongue to dissolve
as an injection or drip
as a suppository, which is a capsule that you put into your rectum (back passage) so that it can dissolve
through a patch that you place on your skin
Continue to take your anti-emetics even if you do not feel sick because they will help prevent your symptoms from returning.
Side effects of anti-emetics include:
Constipation
Flushing of the skin
Problems sleeping (insomnia)
Indigestion
Headaches
There are several different types of anti-emetics. If the one you are taking doesn't work or if it causes too many troublesome side effects, contact Dr. B C Shah. There may be an alternative anti-emetic that works better for you.
Hair loss
Hair loss is a common side effect of some chemotherapy. It usually begins one to three weeks after the first chemotherapy dose. The hair that grows on the side of your head, near your ears, becomes more brittle and thin. Most people have significant hair loss after one to two months.
The scalp is most commonly affected, although hair loss can occur on other parts of the body. These include the arms, legs and face.
Hair loss can be very traumatic, particularly for women.
If you find hair loss particularly difficult to cope with, talk to Dr. B C Shah. They understand how distressing it can be and will be able to give you support and counselling.
You may decide that you want to wear a wig.
Hair loss due to chemotherapy is almost always temporary, and your hair should begin to grow back soon after your treatment has finished.
Around three-quarters of people no longer need to wear a wig or use a head covering six months after their chemotherapy treatment has finished.
Many people find that their newly grown hair is different than before. For example, it may be a different colour or it may be curlier or straighter than it used to be.
Cold cap
It may be possible to prevent hair loss due to chemotherapy by using a cold cap.
A cold cap looks similar to a bicycle helmet. It is designed to cool your scalp while you receive a dose of chemotherapy. In cooling the scalp, the cold cap reduces the amount of blood flow to the scalp. This reduces the amount of chemotherapy medication that reaches it.
Whether or not you can use a cold cap during treatment will depend on the type of cancer you have.
For example, a cold cap cannot be used if you have:
various types of leukaemia, such as acute lymphoblastic leukaemia, which is cancer of the blood cells and mainly affects children
multiple myeloma, which is a cancer that develops inside the bone marrow
non-Hodgkin's lymphoma, which is a cancer that develops inside the lymphatic system (a series of glands and vessels that help protect the body against infection)
With these types of cancers, there is a good chance that cancerous cells could have spread to your skull. Therefore, it would be too dangerous to cool your skull.
Cold caps work better with certain types of chemotherapy medications, and they may not always prevent hair loss.
Increased risk of infection
Chemotherapy lowers the amount of white blood cells in your body. The main function of white blood cells is to fight infection. If the number of white blood cells is reduced, your immune system will be weakened and you will be more vulnerable to infection.
You may be given a course of antibiotics to reduce your risk of developing an infection. You will also need to take extra precautions to protect yourself against infection. For example, you should:
Have good personal hygiene – take daily baths or showers and make sure that clothes, towels and bed linen are washed regularly.
Avoid contact with people who have an infection, such as chickenpox or flu.
Wash your hands regularly with soap and hot water, particularly after going to the toilet and before preparing food and eating meals.
Take extra care not to cut or graze your skin – if you do, clean the area thoroughly with warm water, dry it and cover it with a sterile dressing.
The regular blood count tests that you will have during chemotherapy mean that your Dr. B C Shah should be able to tell you when you are most vulnerable to infection.
You may be advised to take extra precautions, such as avoiding crowded places and using public transport at busy times.
Anaemia
Chemotherapy will lower the amount of red blood cells. These cells carry oxygen around the body. If your red blood cell count drops too low, your body will be deprived of oxygen and you will develop anaemia.
Symptoms of anaemia include:
tiredness – you will feel much more tired than the general level of fatigue associated with chemotherapy
lack of energy
shortness of breath (dyspnoea)
irregular heartbeat
If you have any of these symptoms, contact your Dr. B C Shah as soon as possible.
You may need to have a blood transfusion to help increase the number of red blood cells. Alternatively, a medication called erythropoietin (EPO) can stimulate the production of red blood cells.
It is important to eat a diet that is high in iron. This is because iron helps red blood cells carry more oxygen. Foods that are high in iron include:
dark-green leafy vegetables, such as spinach
iron-fortified bread
beans
nuts
meat
apricots
prunes
raisins
Bruising and bleeding
Chemotherapy can lower the amount of platelets in your body. Platelets are blood cells that help blood to clot (thicken). This prevents excessive bleeding or bruising.
Most chemotherapy medications do not seriously affect the number of platelets. However, a small number of people experience a significant drop in their platelet count.
Symptoms of a low platelet count include:
easily bruised skin
nose bleeds
bleeding gums
Report any of these symptoms to Dr. B C Shah as you may need a blood transfusion to raise your platelet count.
You may need to take extra precautions to avoid damaging your skin and gums including:
using an electric razor to shave
using a soft toothbrush
taking extra care when using knives or other sharp instruments
wearing a thick pair of gloves when gardening
Oral mucositis
In some cases, chemotherapy can cause pain and inflammation of the surface of the inside of your mouth. This is known as oral mucositis.
The severity of your symptoms usually depends on the strength of your medication. People having high-dose chemotherapy usually have more severe symptoms.
The symptoms of oral mucositis usually begin 7 to 10 days after you start chemotherapy.
If you develop oral mucositis, the inside of your mouth will feel sore, as if you have burnt it by eating very hot food. You will probably develop ulcers on the lining of your mouth and, in some cases, on your tongue or around your lips.
The ulcers can be very painful and make it difficult to eat, drink and talk. They may also bleed and become infected.
The symptoms of oral mucositis should clear up a few weeks after your chemotherapy finishes, although a number of medications are available to relieve the symptoms.
Loss of appetite
Some people who have chemotherapy lose their appetite and do not feel like eating or drinking. If you lose your appetite, it is still important to make an effort to eat healthily and drink plenty of liquids.
You may find eating smaller, more frequent meals better than eating three large meals a day. Try sipping drinks slowly through a straw rather than drinking them straight from a glass.
If you have serious problems eating and drinking due to symptoms such as mouth ulcers, you may need to be admitted to hospital and attached to a feeding tube.
You will probably be given a nasogastric tube. This is a tube that passes down your nose and into your stomach. The tube can be removed once you are able to eat and drink normally.
Skin
Some chemotherapy medications can cause your skin to become dry and sore, particularly on your hands or feet. Your nails may become brittle and flakier than usual and white lines may develop across them.
During chemotherapy and for some time after treatment has finished, your skin may become more sensitive to sunlight. Therefore, it is important to take extra precautions to protect your skin from the sun:
Avoid going out in the sun when it is at its hottest – this is usually between 10am and 2pm, although the sun can also damage skin before and after these times.
Use a sunscreen that blocks both ultraviolet A (UVA) and B (UVB) radiation and has a sun protection factor (SPF) of at least 15.
Dress to protect your skin from the sun – for example, wear a wide-brimmed hat to protect your face and scalp and sunglasses to protect your eyes.
Memory and concentration
Some people who have chemotherapy have problems with their short-term memory, concentration and attention span. You may find that routine tasks take much longer than usual.
Exactly why these symptoms appear is unclear. They may be due to a combination of factors, such as fatigue and anxiety. However, the symptoms usually improve after your treatment has finished.
Sleep problems
Sleep problems are a common side effect of chemotherapy. They are thought to affect around half of all people being treated with chemotherapy.
Sleep problems can include difficulty falling asleep (insomnia), and waking up in the middle of the night and being unable to get back to sleep.
The following advice may help to improve your sleep:
Go to bed only when you are sleepy.
If you cannot sleep, leave the bedroom and only return when you feel sleepy.
Only use your bedroom for sleeping and having sex.
Avoid napping during the day. If this is not possible, try to limit your naps to about half an hour.
Avoid stimulants, such as caffeine, for at least six hours before you plan to go to bed.
If this advice does not work, contact your Dr.B C Shah. You may need additional treatment. A type of talking therapy called cognitive behavioural therapy (CBT) has proved to be effective in treating insomnia associated with chemotherapy.
Sexuality and fertility
Many people find that their interest in sex decreases during chemotherapy. However, this is usually temporary and your interest in sex should gradually return after your treatment has finished.
Some chemotherapy medications can stop women being able to conceive and can prevent men from producing healthy sperm. Loss of fertility is usually temporary, although in some cases a person can become permanently infertile.
If there is a risk that you could become permanently infertile, your Dr. B C Shah will discuss the possibility with you before treatment begins.
A number of options are available. Women can have their eggs frozen to be used later in IVF (in-vitro fertilisation). Men can have a sample of their sperm frozen to be used at a later date for artificial insemination.
Diarrhoea and constipation
You may have diarrhoea or constipation a few days after you begin chemotherapy. Dr. B C Shah can recommend suitable medication to help control the symptoms.
Depression
Living with the effects of chemotherapy can be frustrating, stressful and traumatic. It is natural to feel ongoing anxiety and concern about whether your treatment will be successful.
Stress and anxiety can increase your risk of getting depression. You may be depressed if you have been feeling particularly down for two weeks or more and you no longer take pleasure in the things that you used to enjoy.
Contact Dr. B C Shah if you have psychological and emotional difficulties. They will be able to recommend treatments to help improve the symptoms of stress, anxiety and depression.
Joining a support group for people who are having chemotherapy may also help. Talking to other people in a similar situation can often reduce feelings of isolation and stress.
Refusing or withdrawing treatment
In some circumstances, you may think that the benefits of chemotherapy are not worth the poor quality of life due to the side effects of treatment.
For example, if chemotherapy offered no hope of a cure and could only extend your life by a few months, you may feel that the extra few months are not worth undergoing treatment.
However, if you were looking forward to an event such as the birth of a grandchild or the wedding of a son or daughter, you may want to extend your life whatever the cost to your wellbeing.
There is no right answer or recommendation about when chemotherapy should be refused or withdrawn. Dr. B C Shah can give you advice about the likely benefit of continuing with treatment, but the final decision will be yours.
This is obviously a very sensitive topic that you should discuss fully with Dr. B C Shah, family, friends and loved ones. You always have the right to refuse a particular treatment or to ask for the treatment to be stopped if you do not feel it is benefiting you.
Stopping chemotherapy does not mean that any symptoms you have will go untreated. Dr. B C Shah will still provide support and pain relief. This type of care is known as palliative care.
If it's thought that you do not have long to live, it may be recommended that you are admitted to a hospice. Hospices provide care for people from the point at which their illness is diagnosed as terminal to the end of their life, however long that may be.


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Feb13
Radiotherapy
Introduction
Radiotherapy, also known as radiation treatment, is the controlled use of high energy X-rays to treat many different types of cancer. About 4 out of 10 people with cancer have radiotherapy.
In some cases, radiotherapy can also be used to treat benign (non-cancerous) tumours.
The length of each course of radiotherapy will depend on the size and type of cancer and where it is in the body.
Uses of radiotherapy
Radiotherapy may be used:
To cure an illness - for example, by destroying a tumour (abnormal tissue)
To control symptoms - for example, to relieve pain
Before surgery - to shrink a tumour to make it easier to remove
After surgery - to destroy small amounts of tumour that may be left
Radiotherapy is sometimes used to treat thyroid disease, as well as some blood disorders and other benign conditions. This topic focuses mainly on the use of radiotherapy as a treatment for cancer.
Types of radiotherapy
Radiotherapy can be given in two ways. It can be given from:
Outside the body (external radiotherapy) – using X-rays, small particles called electrons or, in rare cases, other particles such as protons; external radiotherapy is usually given once a day as a course of treatment over a number of days or weeks
Within the body (internal radiotherapy, also known as brachytherapy) – either by drinking a liquid that is absorbed by the cancerous cells or by putting radioactive material into, or close to, the tumour, usually for a small number of treatments (brachytherapy) or by injecting or drinking a liquid that is absorbed by the cancerous cells – for example, radioiodine for thyroid cancer
Courses of radiation
Radiotherapy is usually given as a course of treatment that lasts for a number of days or weeks.
Most people who have radiotherapy to treat a serious condition, such as cancer, have five treatments a week (one treatment a day, Monday to Friday) with a break at the weekend. Taking a break allows the normal, non-cancerous cells to recover.
In some cases, treatment may be given more than once a day or over the weekend.
Fractions
Radiation treatment is divided into a number of small doses called fractions, which are usually given over a number of weeks. Fractions are used to reduce the side effects of a full dose of radiation. The number of fractions required will depend on the type of cancer being treated.
Combination therapy
Radiotherapy is often used in combination with other treatments, such as chemotherapy (powerful medication that is used to treat cancer). This is known as chemoradiotherapy.
Chemoradiotherapy can be used to try to cure a cancerous tumour, to shrink a tumour before it is removed using surgery, or after surgery to reduce the risk of relapse.
How radiotherapy works
External radiotherapy
During external radiotherapy, a machine called a linear accelerator focuses high-energy X-rays or other high-energy beams at the cancer. Radiation kills the cancerous cells but also causes temporary damage to healthy, non-cancerous cells, resulting in side effects, most of which are temporary because normal tissues are able to repair themselves.

If radiotherapy is recommended, you will be referred to a specialist radiotherapy (oncology) department where you will receive your treatment. The type of machine that is used will depend on the reason for your treatment and the condition that you are being treated for.
You will not feel any pain during the treatment, but later you may experience some discomfort from the side effects of the treatment. Most side effects do not usually last long.
Internal radiotherapy
Internal radiotherapy uses radioactive materials (metal implants or liquids) to treat cancer. The two types of radioactive material are described below.
Radioactive implants (brachytherapy)
Radioactive implants are usually metal wires, seeds or tubes. They are inserted into or close to the cancerous tumour in a procedure that is known as brachytherapy.
The length of time that the radioactive implant is left inside your body will depend on the type and nature of your cancer. It could be a few minutes or a few days. In some cases, radioactive implants may be left inside the body permanently.
Radioactive metals, such as caesium and iridium, are sometimes used to treat prostate cancer, cancer of the womb, cervical cancer and vaginal cancer.
Radioactive liquids
Radioactive liquids to treat cancer are given either as a drink or an injection. The radioactive part of the liquid is known as an ‘isotope’.
Radioactive liquids include:
Phosphorous - which is used to treat blood disorders
Strontium - which is used to treat secondary bone cancers
Iodine - which is used to treat benign (non-cancerous) thyroid conditions and thyroid cancer
Safety
Health risks associated with radiotherapy are usually minimal because the radiation dose received by the rest of the body is usually very low.
However, as internal radiotherapy involves placing radioactive substances inside your body, there are some safety issues that you will need to discuss with your treatment team.
How radiotherapy is performed
Radiotherapy is only used if the benefits outweigh the risks. Your treatment team will discuss the risks of any radiotherapy procedures that are recommended for you.
Before having radiotherapy, you will be asked to sign a consent form to confirm that you agree to the treatment and understand any risks involved.
Treatment plan
Your treatment will be carefully planned to ensure that the radiotherapy destroys as many cancerous cells as possible, while affecting as few healthy cells as possible.
The amount of radiotherapy you have will depend on:
Where the cancer is in your body
The type and size of the cancer
Your general state of health
In planning your treatment, a radiotherapist (radiotherapy specialist or clinical oncologist) will use all the information gathered during your diagnosis. They may also carry out some additional tests to find out more about the size and site of the cancer and to get a clearer understanding of the area of your body to be treated.
Once your oncologist has all the relevant information, they will calculate the total dose of radiotherapy that you need and the number of individual doses (fractions) required.
If you are having external radiotherapy, a simulator machine will be used as part of your treatment planning. The simulator moves in the same way as the machine that will be used for your treatment. It uses X-rays to take pictures so that the radiographer knows how to position your body when you have your treatment. A radiographer is a healthcare professional who is trained in taking X-rays.
Many patients will also have a computerised tomography scan (CT) scan to help the oncologist to target their tumour accurately.
After the exact area of your body to be treated has been established, the radiographer will put small but permanent ink marks on your skin to ensure that the same area is treated each time.
If you are having external radiotherapy to your head or neck, or if it is difficult for you to keep the part of your body having treatment still, a plastic mould will be made for you to wear during treatment. In this case, the ink markings will be made on the mould rather than on your skin.
External radiotherapy
If you are having external radiotherapy, you will usually receive your treatment as an outpatient, which means that you will not have to stay in hospital overnight. You may need to stay in hospital if you are having chemotherapy in combination with radiotherapy (chemoradiotherapy), or if you are unwell.
During the procedure, you will be positioned on a treatment table and a radiotherapy machine (linear accelerator) will direct high-energy rays at the area being treated.
You will need to keep as still as possible throughout the treatment. The procedure only takes a few minutes and is completely painless. You will be able to breathe normally during your treatment.
While you are having treatment, you will be left alone in the treatment room. A radiographer will operate the machine from outside the room and will watch you through a window or on closed circuit television. If necessary, you will be able to talk to the radiographer during the procedure using an intercom.
Internal radiotherapy
Internal radiotherapy can be given as an implant, drink or injection. Depending on the type of treatment being used, you may need to stay in hospital for a short period of time.
Radioactive implants
If you have a radioactive implant or radioactive liquid, your hospital will have a number of safety guidelines in place to ensure that hospital staff and visitors are not exposed to radiation. Hospital staff will explain the safety procedures to you before your treatment.
Radioactive implants are placed into, or next to, the cancerous tumour so that it gets the highest possible dose of radiation. Although the area close to the implant will also get a high dose of radiation, other parts of your body will receive a very small amount of radiation which is not a risk to your health.
If you are having a radioactive implant, you may need to stay in hospital for a few days until the radioactive source is removed. After the implant has been removed, you are not a risk to others.
Permanent implants do not present a risk because they produce a very small amount of radiation that gradually decreases over time.
Liquid radiotherapy
After having liquid radiotherapy, you may be radioactive for a few days. This will not cause any long-term harm to your body, but you will probably have to stay in hospital until the radioactivity decreases. This is a precautionary measure to reduce other people’s exposure to radiation.
You will be able to leave hospital after the radiation has fallen to a safe level. Dr. B C Shah may give you some safety advice to follow for a few days when you get home.
If there is anything about your treatment that you do not understand, or if there is anything you are unsure about, you should ask a member of your treatment team to explain it to you in more detail.
Common side effects of radiotherapy
Following radiotherapy, it is highly likely that you will have some side effects. Side effects occur because radiotherapy temporarily damages some of the healthy cells as well as destroying the cancerous ones.
Side effects will depend on:
The part of your body being treated
The dose of radiotherapy
How quickly the healthy cells are able to repair the damage
Radiotherapy affects different people in different ways and it is difficult to know exactly how you will react to the treatment.
Some people experience mild side effects following radiotherapy, while others experience more severe effects. Some side effects begin during treatment whereas others can appear weeks or months afterwards.
Before starting treatment, you should discuss the possible side effects with your treatment team.
Common side effects of radiotherapy include:
Sore skin
Tiredness
Feeling sick
Dry mouth
Loss of appetite
Diarrhoea
Dair loss
discomfort on swallowing
a lack of interest in sex
stiff joints and muscles
These are explained in more detail below.
Sore skin
Your skin may become red and sore in the area being treated towards the end of a course of radiotherapy, or for a couple of weeks afterwards.
Depending on the area being treated, and the individual’s reaction to radiation, some people’s skin may peel after having a course of radiotherapy. This usually heals within a couple of weeks.
Dr. B C Shah will be able to give you advice about the best way of caring for your skin during treatment. If your skin becomes sore, you should try not to irritate it further.
You should avoid shaving and using perfumed soap in the affected area. Protect your skin from cold winds and wear a high-factor sunscreen (SPF 15 or above) to protect your skin from the sun.
Tiredness
You will probably feel tired both during and after having radiotherapy. Doing some gentle exercise may help to relieve the symptoms of tiredness.
Tiredness is particularly common towards the end of a course of radiotherapy and it can last for some time afterwards. It usually occurs as a result of the body repairing the damage to healthy cells.
A shortage of red blood cells (anaemia) can also contribute to tiredness during radiotherapy.
For some cancers, regular blood tests may be required during radiotherapy to ensure that you are not becoming anaemic. If you have anaemia, you may need to have a blood transfusion (where you receive blood that is removed from another person who is known as a donor).
Feeling sick (nausea)
Most people are not sick during radiotherapy. However, some people feel sick (are nauseated) at the start of, during, or for a short time after, their treatment. If you experience nausea, your doctor may be able to prescribe medication to help control it.
Radiotherapy to your abdomen (tummy area) or pelvic area may make you sick. This can last a few days after your treatment stops. Again, medication or complementary therapies can help.
Loss of appetite
The combination of feeling sick and tired during radiotherapy can make you lose your appetite. You may have difficulty swallowing if you are having radiotherapy to your head, neck or chest.
If you have difficulty eating, you may find it easier to eat several small meals throughout the day, rather than a few larger meals. You can also speak to your radiotherapist who may refer you to a dietitian (nutritional specialist).
Diarrhoea
Diarrhoea is a common side effect of radiotherapy to the abdomen or pelvic area. It usually starts a few days after treatment begins and gradually gets worse as treatment continues. You should tell your doctor if you notice any blood in your stools (faeces).
After your treatment has finished, diarrhoea should disappear within a few weeks. You should tell your doctor if your symptoms have not improved after a few weeks.
Hair loss
Hair loss is a common side effect of radiotherapy to your head or neck. Radiotherapy will only cause hair loss in the area being treated.
Many people find losing their hair stressful and difficult to cope with. Losing your hair can affect your self-confidence and it may make you feel depressed.
Talk to your family and friends about how you are feeling so that they can support you. After a few weeks of finishing treatment, your hair should start to grow back.
You may consider getting a synthetic (man-made) wig or a wig that is made from human hair.
Inpatients (those who need to stay in hospital overnight for treatment)
Those under 16 years of age
Those between 16 and 19 years of age who are in full-time education
Discomfort on swallowing
Radiotherapy to the chest can cause the tube through which food passes (the oesophagus) to become temporarily inflamed, which may cause temporary discomfort when swallowing. If required, Dr. B C Shah will be able to prescribe medication to help soothe your throat.
Effects on sex and fertility in women
Having radiotherapy may cause you to lose interest in sex, particularly if you have other side effects, such as tiredness or nausea, or if you are anxious about your condition or treatment.
You should avoid eating hot or spicy food and drinking acidic drinks or spirits during this time because they can aggravate the problem.
Radiotherapy to the vaginal area may cause your vagina to become sore and narrower. Your radiotherapist will tell you how you can treat this using a vaginal dilator, which is a device that is inserted into your vagina to help prevent it narrowing. Having sex regularly after your treatment can also help prevent your vagina narrowing.
If you experience vaginal dryness or pain when having sex, you can use lubricants or Dr. B C Shah to prescribe appropriate medication. Radiotherapy to other areas of the body will not affect your ovaries or make you infertile.
Effects on sex and fertility in men
In men, temporary erectile dysfunction (the inability to get and maintain an erection) and loss of interest in sex are common side effects of pelvic radiotherapy.
Radiotherapy to other areas of your body will not make you infertile or cause any problems if you decide to have children in the future.
If there is a risk that you could become infertile following radiotherapy, your doctor will discuss this with you before your treatment.
Stiff joints and muscles
Radiotherapy can sometimes cause your muscles to tighten up and your joints to become stiff in the area being treated. You may also experience some uncomfortable swelling in the affected area.
Exercising your joints and muscles regularly can help prevent stiffness. If you have stiff joints and muscles, your doctor or radiotherapist may refer you to a physiotherapist, who will be able to recommend suitable exercises for you.
Long-term side effects of radiotherapy
It is rare to develop severe, long-term side effects as a result of having radiotherapy. Your doctor will discuss the likelihood that you will experience side effects before you consent to treatment.
Sometimes, side effects can occur years after finishing a course of radiotherapy. Some of these may be permanent and can include:
Effects on fertility
Cosmetic changes to the skin
Tiny cracks in your pelvic bones (pelvic insufficiency fractures)
An inability to control your bowel (bowel incontinence)
Swelling in your arms or legs (lymphoedema)
These are discussed in more detail below.
Infertility and early menopause
In women, radiotherapy to the pelvic area exposes the ovaries to radiation. In pre-menopausal women, this may cause early menopause (where a woman's monthly periods stop) and infertility (the inability to get pregnant). This is often very upsetting, particularly for younger women who want to have a family.
Before having treatment, your doctor will discuss all the options and available support with you. For example, it may be possible for some of your eggs to be surgically removed, frozen and stored until you are ready to have a baby.
Cosmetic changes to the skin
Long-term changes to the skin can occur after having radiotherapy. Some people notice that their skin is thicker, a slightly darker colour and, occasionally, dimpled (like the peel of an orange). These changes usually improve over time.
Pelvic insufficiency fractures
Radiotherapy to your pelvic bones can cause tiny cracks, known as pelvic insufficiency fractures, to appear in the bones of your pelvis some time after treatment has finished. Pelvic insufficiency fractures are more likely to occur in people who have osteoporosis, a condition that causes brittle bones.
Pelvic insufficiency fractures can be very painful, particularly during exercise. Resting should help to reduce the pain. You should report any new bone pain that you experience to your oncologist or GP.
Bowel incontinence
Bowel incontinence, sometimes known as faecal incontinence, is a rare side effect of radiotherapy to the pelvis. It is the inability to control your bowel movements which can result in faeces (stools) leaking from your rectum (back passage).
Bowel incontinence can be treated with dietary changes, medicines or a number of different surgical procedures.
Lymphoedema
Radiotherapy can damage your body’s network of channels and glands that make up the lymphatic system. One of the functions of the lymphatic system is to drain excess fluid from your tissues. If the lymphatic system is damaged, fluid can build up and cause swelling and pain.
This is known as lymphoedema and it often occurs in the arms or legs although it can also affect other areas, such as the chest. Lymphoedema is usually associated with women who have had radiotherapy for breast cancer.
It may be possible to prevent lymphoedema occurring using appropriate skincare techniques and exercise.
Recovering from radiotherapy
Most side effects of radiotherapy only last for a few days or weeks after treatment has finished. However, some side effects, such as tiredness or hair loss, can last for a few months.
Follow-up appointments
After your course of radiotherapy has finished, you will have an appointment with your oncologist (a cancer doctor who specialises in radiotherapy) to check on your progress.
You may need to have follow-up appointments for several years, but they will usually become less frequent as time passes.
Dr. B C Shah will be sent a report about your treatment. You will also be able to contact a member of your treatment team if you have any questions after your course of radiotherapy has finished.
Effects of radiotherapy
Despite the side effects mentioned here, radiotherapy can be a highly effective treatment, either in curing or controlling a cancer, or relieving symptoms.
The positive effects of radiotherapy usually take some time to become apparent. The treatment's benefits will depend on the type of cancer that you have and how advanced it is when treatment begins.
The effectiveness of your radiotherapy treatment may also depend on whether you are having other forms of treatment alongside radiotherapy, such as chemotherapy or surgery.


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Sep15
Fracture Nasal Bone
(Patient information sheeth)
Fracture Nasal Bone
The disease: This is a common condition where the bone on your nose gets fractured and leads to either disfigurement and /or nasal obstruction
Diagnosis : This is done based on examination of patient. A Xray is don’t just to confirm the diagnosis. However clinical examination of patient remains the main stay for diagnosis
Treatment : The reduction of fracture is done either immediately within 4 hrs of injury or we wait for 3-4 days for the swelling over the nose to reduce.
Surgery : This is a procedure that causes some pain to patient so it is preferred to be done under full (general)Anesthesia
This entire procedure takes around 30 min.
Before surgery : Patient has to remain empty stomach for 8 Hrs. No food and water to be consumed 8 hrs before surgery.
Post surgery :
Patient has a nasal pack in his nose and he has to breathe from mouth. This pack is kept for 24-48 hrs, depending on the type of injury and amount of blood loss
You will be kept hospitalized for 1-2 days. This might be different for each patient.
A plaster of paris ( POP) cast would be kept on the nose to support and stabilize the reduced fracture. This has to be kept for 7-10 days. After that POP has to be kept only while sleep.
There is no specific dietary restriction after the surgery.
Patient can carry on with his routine day to day hectic. He has to avoid any such condition that can lead to injury to nose. Even minor injury to nose has to be avoided
Complications of Surgery: This is generally a safe surgery. However general complication of allergy to any drugs and reaction to anesthesia drugs might happen. These are very rare now a days.
As for surgery there are no major complication. However in ALL the patients after the surgery there will be some swelling on the face and around the eyes and this goes away in 2-3 days.
This is for your information and if any further clarifications needed contact your doctor
Dr (major) Prasun Mishra
MS ENT ( AFMC), DNB ( ENT)
9881676449


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Jan05
Emergency Department staffing
The Emergency Department (ED), sometimes termed Accident & Emergency (A&E), Emergency Room (ER), Emergency Ward (EW), or Casualty Department is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, Emergency Departments have become important entry points for those without other means of access to medical care. Staff teams treat emergency patients and provide support to family members. The emergency departments of most hospitals operate around the clock, although staffing levels attempt to mirror patient volume, which in most ED's finds its nadir between 2:00 am and 6:00 am. Most patients seek the Emergency Department in the afternoon and evening hours, and staffing mirrors this phenomenon.
The vast array of people caring for patients in an emergency department can be quite confusing to the average health care consumer -- as confusing.
Additionally, most people are uncertain of the training and background necessary to become a member of the emergency-department team. Well, here's the scorecard.


Emergency Physician
Physician who specializes in the care of patients with acute injuries or with diseases that are an immediate threat to life or limb. A "board certified" specialist in emergency medicine is an emergency physician who has achieved certification by the American Board of Emergency Medicine (if an MD) or the American Osteopathic Board of Emergency Medicine
Emergency Nurse.
Nurses care for patients in the emergency or critical phase of their illness or injury. A specialist nurse who will independently assess, diagnose, investigate, and treat a wide range of common accidents and injuries working autonomously without reference to medical staff. They primarily treat a wide range of musculoskeletal problems, skin problems and minor illness, many are considered experts in wound management. They are trained in advanced nursing skills which though medical in nature - such as taking a full medical history and examination, x-ray interpretation, prescribing, suturing, & plastering, also encompass a holistic assessment of the patients needs, taking into account the need for health teaching and education, continuing care within the family and ongoing health support in the community.
PhysicianAssistant
Many emergency departments utilize physician assistants (PA). PAs work under the supervision of an emergency physician. They can examine, diagnose and treat patients (usually the less complicated ones) and review their findings with the physician.
EmergencyDepartmentTechnician
The tasks that performed may include taking your vital signs, drawing your blood, starting your IV, performing EKGs, transporting you to and from various tests, and providing aid and comfort to family and friends.
UnitSecretary
This essential member of the team is one you don't hear about very often. He/she often handles the communication needs of the ER. A few important examples of important communication needs include the emergency physician needing to speak to the patient's family physician, families calling about their loved ones, family physicians needing to inform the emergency department about patients being sent in, or patients calling in needing medical advice. Also, he/she coordinates the ordering of diagnostic tests.
Physicianintraining
An attending physician who usually has extensive experience in emergency medicine supervises these physicians. There are ways to bridge the nursing productivity gap, while improving staffing processes, improving efficiency, and creating a vision for the future. To improve staffing processes one has to increase forecasting accuracy, match staffing to demand, increase management vigilance, smooth the workload variation and enhance nurse efficiency in the emergency room.
In the hospital industry cost information plays a critical role in maintaining a competitive advantage. Strategic cost management allows us to provide low cost care. For example, reducing the cost of providing care by improving a process would allow the organization to reduce the cost to the patient, thus reducing customer sacrifice.
Managers will be forced to determine which activities are important if customer value is emphasized. The healthcare industry requires that managers be familiar with many functions of the financial end of business. Nurses have often looked the other way when it comes to finances and continually focused on patient care. In the year 2001 the attitudes and focus must shift to keeping the healthcare facility viable in the business world. Relating patient care, hours worked, and the number of nurses required to provide low cost, quality care is of extreme importance in today’s environment. This broader vision allows managers to increase quality, reduce the time required to service customers (both internal and external), and improve efficiency. Continuous improvement is fundamental for establishing a state of healthcare excellence.


Next-day productivity profiling holds each manager accountable for the outcome of his or her specific area and to manage his or her resources appropriately. Imprecise staffing standards and infrequent monitoring hinders flexing of staff and leaves managers unaccountable for productivity. The emergency department will be profiled daily on performance against productivity targets. They will use productivity standards and daily volumes to determine real-time, the amount of staff needed to meet the demand. In most cases, the core staff will already be in place, and only upward adjustments will prove necessary. Managers are being trained to look at the business, and to be able to forecast the needs of the units and react to the needs efficiently. It is the expectation that this process will become routine, requiring moderate effort to maintain.
To improve emergency department staffing a master schedule of worked hours is reviewed daily to determine the daily census and volume and the per shift census and volume. Then the total worked hours scheduled is evaluated along with the worked hours per shift per unit. Managers are actually evaluating labor on a shift-to shift basis. Real-time reporting of adherence to customized productivity standards enables more accurate matching of staffing to demand. This process prevents hiring unnecessary personnel and fosters a permanent focus on staff efficiency and cost control.
Study also shows that that between the hours of one am and ten am, historically the census is low and requires less staffing. The emergency department survey also reflected that the peak volume times in the emergency department were from 10am to 12 midnight and this has provided needed information on start times and these surveys were utilized in formulating the schedule. It is essential to obtain staff buy-in to effectively implement this process in any organization.
Implementation of the Emergency Department Productivity Profiling System will reduce the number of FTE'’ needed per shift. This will further reduce cost associated with labor, as staff will be utilized more efficiently during peak arrival times. Thus, allowing to accurately plan for core and flexible staffing needs. Managers will be held accountable to department-specific hours-per-unit targets for flexible staffing. In turn, managers will be provided with timely, structured feedback on their performance against these targets. The staffing matrix developed for the Emergency Department will be adjusted periodically to further improve performance and reflect process or technology changes should they be needed.

References

Alba, T. (2000). Next-Day Productivity Profiling. Healthcare Advisory Board (Ed.), Nursing Cost Advantage, (Volume III, pp. 43-49). Washington, D.C.: The Advisory Board Company.
Ansari, S. (2000, March). Activity Based Management. Retrieved June 19, 2001 from the World Wide Web: http://www.wku.edu/~aldricr/.
Bellandi, D., Kirchheimer, B., & Galloro, V. (2001). Overall, not so bad. Modern Healthcare, Volume 31, pp. 36-37.
Coates, K. (2001, June). Trickle-down Effect. Nurse Week, Volume 6, p.13.
Covey, S. (1991). Managing Expectations. In Covey, S. (Ed.), Principle-Centered Leadership (pp. 204-205). New York, New York: Franklin Covey Co..
Hansen, D., & Mowen, M. (2000). Current Focus of Management Accounting. In Sears, M. (Ed.), Management Accounting (5th ed., pp. 10-15). Cincinnati, Ohio: South-Western College Publishing.
Nelson, D., & Quick, J. (2000). Forces for Change in Organizations. In J. Szilagyi (Ed.), Organizational Behavior (Third ed., p. 602). Cincinnati, Ohio: South-Western College Publishing.
Parker, C. (2001, June 11). AHA report shows staffing shortages threaten access to quality health care. AHA News, pp. 1, 2.
Pearson, C., & Barton, L. (2001). Vacancy Review Council. The Healthcare Advisory Board (Ed.), Liberating Hospital Economics, Volume I, pp. 37-43). Washington, D.C.: The Advisory Board Company.
Shaffer, F. (2001). On the Front Lines: A scan of the organizations that influence practice. Curtain Calls, Volume 3, p. 3.
Solovy, A. (2001). Mission Makes Wall Street. Hospitals & Health Networks, Volume 75, p. 38.


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May18
AN EXPERIENCE OF TREATMENT FOREARM FRACTURES BY CLOSED NAILING
AN EXPERIENCE OF TREATMENT FOREARM FRACTURES BY CLOSED NAILING
DR.K.HYDAR. ORTHOPAEDIC SURGEON, MALABAR HOSPITAL, MANJERI, KERALA, INDIA.

Introduction.

The Forearm fracture requires an aggressive and exacting management, as it serves an important role in the upper extremity function. There are a variety of options for treating fractures of forearm like cast immobilization. Plate fixation, Intramedullary fixation and external fixation.

Aim of the study is to asses the result of closed nailing, which is less traumatic, less expensive, and to find out the anatomical and functional acceptance of the procedure.

Patients & Method.

In this study 78 forearm fracture ( both bone 58 & single bone 20) treated by closed nailing during December 2000 to June 2003 ( 30 months) at Malabar Hospital, Manjeri, Kerala, India. Age group varies from 12 years to 60 years. 44 were male and 34 were female patients. 26 patients sustained injury following road traffic accidents and 52 patients sustained injury following fall.

After closed manipulative reduction under image intensifier, fixation done with square Nail by closed method. All cases were done under regional block anesthesia. In 30 cases ulna was fixed first and the rest of the cases radius first. In 9 cases because of soft tissue interposition reduction was not stable, so stab incision was made and reduction performed with help of bone leaver. All patients were discharged on the 2nd day. Suture removal was done on 10th day, POP slab converted to above elbow cast for 4 to 6 weeks. After removal of the plaster patient was sent for physiotherapy for 5 days

Results.

AGE GROUP 10 – 20 YEARS.


Fracture
Site

No.
Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
6
1
6
8
8
11
0
1
1

Middle 3rd
10
0
6
8
8
11
0
0
0

Distal 3rd
11
0
6
8
8
12
0
0
1


27
1
6
8
8
11
0
0
2

AGE GROUP 21 – 30 YEARS.


Fracture
Site

No.

Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
2
1
6
8
8
11
1
0
1

Middle 3rd
6
1
6
8
8
11
0
1
1

Distal 3rd
7
0
6
8
10
12
0
0
0


15
2
6
8
8
11
1
1
2

AGE GROUP 31 – 40 YEARS.


Fracture
Site

No.

Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
1
1
6
8
8
10
0
0
0

Middle 3rd
7
0
6
8
8
11
0
0
0

Distal 3rd
8
0
6
8
10
12
0
0
0


16
1
6
8
8
11
0
0
0


AGE GROUP 41 – 50 YEARS.


Fracture
Site

No.

Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
1
1
6
8
8
10
0
0
0

Middle 3rd
5
1
6
8
8
12
0
0
1

Distal 3rd
6
0
6
8
8
12
0
0
1


12
2
6
8
8
12
0
0
2



AGE GROUP 51 – 60 YEARS.


Fracture
Site

No.

Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
2
0
6
8
10
10
0
1
1

Middle 3rd
3
1
6
8
10
12
0
0
1

Distal 3rd
3
0
6
8
10
12
1
0
0


8
1
6
8
10
12
1
1
2

Total 78 7 1 3 8


Results were analyzed by dividing the patients in to different groups depending on age and site of fracture.

In the 1st group, there were 27 patients in the age group of 10 – 20 years, of which 6 had proximal 3rd fracture, 10 had middle 3rd and 11 had distal 3rd fractures. One fracture had difficulty in reduction because of soft tissue interposition. Clinical union by 4-6 weeks and radiological union by 6-8 weeks. All cases had functional union by 10 weeks.

In one of the case of proximal 3rd fracture had delay in union by 2 weeks. Two patients had nail migration which removed after 3 months.

In the 2nd group patients between the age group of 21-30 years, there were 15 patients; of this 2 fractures had difficulty to reduce. All fractures were united Clinically by 6 weeks, radiologically by 6-8 weeks, and functionally by 10 weeks. One case was delayed to unite by 3 weeks. Two patients had nail migration.

In the 3rd group there were 16 patients; one patient had proximal fractures, 7 patients had middle and 8 patients had distal 3rd fractures. One fracture had difficulty in reduction. All cases had functional union by 8 weeks. There were no delayed union or nail migration.

In the 4th group, there were 12 patients, of which 2 had difficulty in reduction. 2 patients had nail migration which was removed after 3 months.

In the 5th group there were 8 cases. In one case reduction was difficult One patient had superficial infection and one had Delayed union. 2 patient had nail migration.





Of these 78 cases, 7 cases had difficulty in reduction which is more in proximal 3rd fractures (4 proximal 3rd and 2 Middle 3rd fracture) especially in muscular patients. These cases were reduced with bone lever through a stab incision.

Delayed union was seen in 3 cases, which was also more in proximal 3rd and Middle 3rd fractures. One patient had superficial infection which is treated with antibiotics.

Of the 78 cases, 8 cases had nail migration, which was treated by nail removal after clinical and functional union.

All cases were united clinically by 6 weeks and radiologically by 8weeks. Functional union by 10-12 weeks. Patients were started working after 12 weeks.

Discussion

Closed nailing for the forearm fractures showed good results, comparing to the other modes of treatment. For forearm fractures DCP is still the gold standard treatment. But considering short operating time (30 – 40 mints) surgical trauma, infection, short hospital stay, less expense and minimal scar, closed nailing is to be considered as an alternate method of treatment.

In this present study, closed nailing gives better results in younger age group of patients (10-20 years). Difficulty in reduction is more in muscular patients and in proximal 3rd fractures. So selection of cases is important for closed nailing. Better results were with Middle and distal 3rd fractures and in younger age group 10-20 years.

Selection of nail is important, considering the length and size of nail. Chances of migration is more in thin and shorter nail. One disadvantage of nailing is the need for immobilization for 6 – 8 weeks . Nail migration may effect elbow and wrist movements.

Conclusion

• Closed Nailing for forearm fracture gives better results.
• For patients of younger age group (10-20) had better results.
• Compared to proximal fractures middle and distal fractures are easy to treat by closed method.
• Considering the economics, trauma, medicine, hospital stay, infection, non-union, bone grafting, and cosmetic aspect closed nailing gives better results




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Sep30
Detection of amino acid markers of liver trauma by proton nuclear magnetic resonance spectroscopy. Liver International 2006: 26: 703–707
OBJECTIVE: We examined serum in patients of liver injury to explore the possible clinical application of abnormal micrometabolites as a marker of liver injury and severity in cases of traumatic liver damage. METHODS: Serum were screened by proton nuclear magnetic resonance spectroscopy in 96 patients with varying degree of liver injury and compared with concentrations in healthy control volunteers. RESULTS: Large quantities of phenylalanine and tyrosine were detected by spectroscopic analysis in patients with liver injury but not in those without liver injury (P < 0.001). Proton nuclear magnetic resonance spectroscopy revealed two unique amino acids, phenylalanine and tyrosine, in the sera of the subjects with liver injury, irrespective of the extent and type of injury gauged by radiology or laparotomy. Phenylalanine spectrum was obtained in all 84 patients with liver injury (100% sensitivity) whereas tyrosine spectrum was present in 83 out of 84 patients (98.8% sensitivity) suggesting that these amino acids were specifically released in the patients of liver injury. Significant correlations were observed between phenylalanine and tyrosine concentrations and total bilirubin levels and albumin levels. Serum phenylalanine and tyrosine concentrations correlated well with imaging and laparotomy findings of liver injury. CONCLUSION: Phenylanaline and tyrosine appear to be specific and new markers of liver injury.


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Sep30
Blunt abdominal injury: Serum ALT- A of liver injury and a guide to assessment of its severity. Injury. 2007; 38: 1069-1074
BACKGROUND: Elevated serum alanine aminotransferase (ALT) as a marker for diagnosis, and assessment of severity in patients with blunt hepatic injuries are hitherto un-described or casually mentioned in literature. METHODS: Prospective observational study of all patients admitted with blunt abdominal trauma accrued between May 2002 and December 2003. Upon admission, vital parameters were recorded and blood samples were drawn for haemogram and serum ALT (SGPT) levels. Patients were further evaluated with USG, CT scan or underwent a laparotomy. RESULTS: Of the 122 patients with blunt abdominal injury, 32 had raised ALT, among these 31 had liver injury. No patient with a normal ALT had hepatic injury. Five patients with a significantly raised ALT and negative USG had liver injury. Patients with modestly raised ALT, mostly resolved on non-operative treatment, whereas, patients with more marked rise had more serious hepatic injuries, more complications, greater transfusion requirement, and higher death rates. CONCLUSION: This observational cohort study strongly suggests that raised serum ALT is a sensitive diagnostic marker for blunt liver injury and its levels may assist with prognosis and guide management.


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