Surgery is Better than Medical Management for Non-Alcoholic Fatty Liver Disease

 

About the Author:

Dr.Abeezar Sarela

Abeezar Sarela specialises in surgery for diseases of the oesophagus and stomach (often referred to as Upper Gastrointestinal Surgery or Upper GI Surgery or Foregut Surgery). There are three areas of sub-specialisation in this area: (1) surgery for obesity & related diseases such as diabetes (Bariatric & Metabolic Surgery);(2) surgery for cancer of the oesophagus and stomach (Surgical Oncology) & (3) surgery for benign disorders, such as gastro-oesophageal reflux disease, hiatus hernia, achalasia cardia and gastroparesis.

He practices in UK at: St James’s University Hospital, Nuffield Hospital, and Spire Hospital. He also operates in India at Hinduja Hospital, Mumbai

Contact: a.sarela@leeds.ac.uk

Website: http://foregutsurgeon.com/ (Powered by Websites For Doctors)

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Waterbirth – Facts vs Myths

Hydrolabour is defined as the use of water during the active phase of first stage of labour. Hydrobirth entails the actual delivery of the baby that is the second and third stage of labour in the pool of warm water.

The equipment used is a disposable inflatable tub about 5 and ½ feet in diameter and two feet tall. The water is maintained at a constant 37* Celsius i.e body temperature which is warm to hot. Monitoring of labour for both patient & baby is just as we do in routine labours.

Patients are admitted early in labour and essentially the entire process of labour remains the same. Due consent is taken for the use of water in labour and delivery. The patient enters the pool of water in the active phase and labours and delivers there.

The baby is born active and calm as the mother holds and brings it out of water after a few seconds of adaptation. The cord is now cut and respiration is established. Placenta delivery may take place in the pool or after shifting the patient out. Episiotomy can be given underwater with local anaesthesia.

The average duration of second stage is shorter and the incidence of instrumentation is lower in patients undergoing Hydrobirth. None of our patients has had any significant 3rd stage complications.

There is absolutely no difference in the neonatal condition at birth or the incidence of neonates requiring resuscitation or other assistance.

 Facts Vs Myths

Myths/ Fears	Scientific Facts
The baby will aspirate water or drown .	There is no attempt to breathe till the cord is cut or exposure to air occurs.
Infection risk to the mother.	Theoretical- never reported in the last 50 yrs.
Infection risk to the baby .	Almost all babies are bathed in most hospitals after birth. We use the same water for our Hydrobirths.
Hygiene?	Disposable equipment available for each patient.
What about Episiotomy & the placenta.	Episiotomy under local anaesthesia can be given underwater. Delivery of the placenta may be done underwater or on the delivery table nearby

So why water?            

• 60% of our body is water!!!
• Water is the essence of life – natural & pure.
• Water is a muscle relaxant it rejuvenates and refreshes.
• Water increases blood supply to the uterus – takes away toxic local hormones.
• Water makes labour more efficient … more progress with lesser number of contractions.
• Gives buoyancy and makes you weightless.
• Results in shorter and less painful labours –without increasing the risk to mother and baby in any way.

In water stress hormones are reduced and pain relieving chemicals or endorphins are released in excess. Also the shock of sudden lights sound and other sensory stimuli to the baby is reduced if the baby goes from water to water to air rather than from water to air directly and these babies are reported to be more balanced and stable individuals who have better adaptive capabilities as adults later on in life.

The subjective reporting of pain relief has us completely stunned and very enthused about what we have seen.

We did not use any drugs or medication to hasten or accelerate these labours which is an important concept of natural birthing.

Benefits of Water Birthing?

1. Water is a muscle relaxant – it aids the passage of the baby through the birth canal.
2. Relives pain.
3. Refreshes & rejuvenates the mother – making her more co-operative
4. Shortens the duration of labour & reduces incidence of artificial instrumentation at delivery (Forceps/Vacuum)
5. Causes weightlessness- overcomes gravity- allows the mother relief and comfort.
6. Gives the baby a smoother medium of transition from the womb to the out side world…..And many, many

Reference Reading:

Cochrane Review : Of more than 40,000 Waterbirths worldwide. No directly attributable fatality and No specific risk above Normal deliveries.

British Medical Journal 1999 : Dr. Gilbert et al. 4032 Waterbirths – Perinatal Mortality 1.2 / 1000 live births. Lower than normal Deliveries.

Choosing Waterbirth : Lakshmi Bertram
Gentle Birth Choices : Barbara Harper
Waterbirth Unplugged : Beverly A Lawrence Beech
Waterbirth Handbook : Eileen Herzberg

www.waterbirth.org
www.waterbirth.com
www.yourwaterbirth.com

About the Author:

Dr. Rajeev Punjabi:  Dr. Rajeev V Punjabi started his Practice in 2000, and spent 4 years performing Sonography in Obst. & Gynaecology, besides working as a Gynaecologist in Mumbai. In July 2003, he joined hands with his colleague from LTMMC, Sion Hospital, Mumbai and long time friend Dr.Sheetal J Sabharwal to start Tulip Women’s Healthcare Centre in Khar(W), Mumbai, India. In October 2003, he performed Mumbai’s First and one of India’s first documented and reported Underwater Deliveries – Hydrobirth successfully. He continues to promote the use of Water in labour and delivery ( Waterbirth ) with great enthusiasm.

You can read more about Tulip and Dr Punjabi at: http://www.tulipwhc.in/ (Powered by Websites For Doctors)

You can also email him at: rvpgynaec@rediffmail.com

THE DILEMAS OF THE MEDICAL PROFESSION

There is a growing distance among the different sections of society, more so between the society at large and the inhabitants of the medical profession. This population is not only minuscule but is under- represented and inarticulate regarding its concerns, anxieties and problems. The spokesmen for the society are numerous and powerful with a ready audience. In this article I will try to be a spokesman for the other side.

The dilemma of choosing a branch of study is faced by all. Only a few choose the medical science as a profession, some out of choice, and many due to coercion by parents or by virtue of having to manage a nursing home to be inherited. Some few wanting to come onto the profession, but not succeeding opt for studies in foreign lands, mostly CIS countries likeRussia, Ukraine etc. Those coming out of choice do come in with a sense of dedication and willingness to serve, but the lengthy course and associated stress soon take their toll on their values. This is compounded when they find their friends and batch mates already into jobs, earning six-figure salaries, while they have to be satisfied with a measly stipend after a longer period of study. Add to that the fact that failure rates being so high, less than half complete their study in the stipulated 5 ½ years.

The next dilemma comes during internship; whether to work and learn during this period of a year (for whish it is intended) or to prepare for the post graduate entrance looming ahead. For in this branch only a student has to continue giving entrances for everything. Not doing a post graduation would leave him without a specialist degree and close further options, leaving him one of the nameless doctors wasting away in the hinterlands of the country for their sustenance. Yet preparing for the same has no guarantee of success, but one may have to spend some years to get through. And during that period, to be dependent on your parents, especially after being a doctor, is a mighty unpleasant experience.

The next dilemma facing the doctor choosing to do the PG is the choice of subject. Actually choice is only for the lucky few at the top of the rankings. For the rest it is only-take it or come back next year.

After completing the PG, the doctor is faced with choices of joining govt service, higher studies, joining pvt sector, or starting own practice. Each has good and bad points in its favour. A govt job gives security but with measly salaries. Of course, don’t count job satisfaction among the attributes, unless you are blessed. Keeping the govt tradition of putting round pegs in square holes, or vice versa, one may have to do works not even remotely connected to medicine. Yours truly had scrutinized scholarship forms and land records and measured areas of houses. Add to that posting in a god forsaken place, where you have to keep everyone happy starting from the local dada to the local leader so that you may survive to ply your trade. Or be prepared to get roughed up for some imaginary mistake you supposedly committed, starting from not attending to a patient to rape/molestation(so newsworthy events).Or better still, grease some palms to get a better posting. Now, this was not in the curriculum, was it? A pvt sector job gives you good salaries, but with no regards to anything else apart from profits. Please let go of your ethics, if you have any left by now. Higher studies entail the same problems described above, during post graduation. Starting your own practice involves a good investment and savings for the time till your practice starts looking up, which may be some years. You have to have an understanding father with deep pockets, so that he may support you, and by that time your wife (and may be kid) for some months(if you are lucky) or years(if not so).

Now assuming that our doctor has solved all this dilemmas, with his values wounded, but alive, he is faced with even more dilemmas. News like “doctor gives injection and patient dies” makes him feel like a cat caught in a car’s headlights. As if all the training he received in a decade and a half was for killing a patient .Also he comes under consumer protection act. Nothing wrong there except for some small points, like if patient is a consumer, why does he grudge you your fees? Oh! The doctor took Rs X for only writing three medicines. He cannot make them understand that the fees are for the expertise gained over years and not for writing only. The patient is always free to go to a ‘shop’ charging less. The other point is that why should other professions not be under copra? After all one can get killed when a bridge or building collapses, or by mosquito bites (dengue, malaria) and so many other causes. He is not sure whether he should attend to a patient brought to him when he is just about to die and try to revive him (which may not be possible medically)and risk being a breaking news for some TV channel, or first make an MLC ,so that his skin is saved, thereby losing a few vital minutes. Whether he should advise an investigation to rule out some problem. If he does, he risks being accused of taking commissions, and if not, then negligence, if the problem is discovered later.

Dilemmas galore, yet these are not the only ones. So many more are experienced, yet untold. Due to the circumstances, under which a doctor has to work, and the negativity which has come to be associated to this profession, the number of students opting for the course has dropped appreciably. After all, why should a student spend the best decade and a half of his best years, toiling away only to do a thankless job. The money and time invested in this course, if invested differently will fetch much higher returns. And the days when a doctor wanted his children to be doctors are long gone. Now he wants them to be anything but a doctor, unless he has an established institution to give in inheritance.

This article is not to discourage anyone from entering this hallowed profession, but to make him aware of the pros and cons of the same. After all being a doctor has its advantages as well, least of them being a no retirement. The joy felt on seeing the thankful smile of a patient expressing his gratitude for his relief, compensates for many of the negatives. This branch of study requires utmost dedication, and concentration over a long period, probably throughout life. If you have it in you, then!

About the Author:

Dr B.K.Kundu,

Rheumatology Clinic,

Department of Medicine,

PGIMER, Dr RML Hospital

New Delhi-110001.

Email: bijit73@sify.com

Do We Treat Male Infertility in the Era of ICSI ? – Dr. Anand K. Shinde

 

About the Author:
Dr. Anand Shinde, M.D., Gyn

IVF Consultant & Director of Andrology At“IVF Pune”, 7th floor Deenanath Mangeshkar Hospital Pune-4
Phone : +91 20 26876396 / 40151777
Mobile : +91 9822012166
Email : shinde.ivfpune@gmail.com

Dr Anand Shinde is Trained in High Risk Pregnancy Management & also in A. R. T. at Birmingham. He currently practices with Nirmiti Clinic and IVF Pune.

Website: http://www.dranandshinde.com/ (Powered by Websites For Doctors)

Ectopic Pregnancy—Medical management an overview

Introduction

The blastocyst normally implants in the endometrial lining of the uterine cavity. ¹Implantation anywhere else is considered an ectopic pregnancy World Health Organization (2007) ,ectopic pregnancy is responsible for almost 5 percent of maternal deaths in developed countries .

Sites – Fallopian tube commonest

 

 

 

 

 

 

Risk Factors

 

Factors Increasing  the Ectopic Pregnancy Rates

• Increasing prevalence of sexually transmitted infections, especially those caused by Chlamydia trachomatis)
• Identification through earlier diagnosis of some ectopic pregnancies otherwise destined to resorb spontaneously
• Popularity of contraception that predisposes pregnancy failures to be ectopic
• Tubal sterilization techniques that with contraceptive failure increase the likelihood of ectopic pregnancy
• Assisted reproductive technology
• Tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty for infertility.

Fate of tubal ectopic pregnancy

Tubal Rupture

Tubal Abortion Abdominal Pregnancy

Broad Ligament Pregnancy

Interstitial and Cornual Pregnancy

Multifetal Ectopic Pregnancy

Symptoms and Signs

 Pain. Pelvic and abdominal pain  – 95 %

Abnormal bleeding. Amenorrhea with some degree of vaginal spotting bleeding -60% to 80 %

Abdominal and pelvic tenderness

Uterine changes

Vital signs ,Fall in Blood Pressure, Tachycardia.

gastrointestinal symptoms (80 percent)

dizziness or light-headedness (58 percent

Diagnosis of Ectopic Pregnancy

BETA-HCG

Serum Progesterone levels-25 ng/mL

Sonography

Culdocentesis

Management

Medical Management–with Methotrexate

This folic acid antagonist is highly effective against rapidly proliferating trophoblast

contraindication

Active intra-abdominal hemorrhage ,intrauterine pregnancy.breast feeding;

immunodeficiency,alcoholism; chronic hepatic, renal, or pulmonary disease;

blood dyscrasias; and peptic ulcer disease.

Patient Selection

The best candidate for medical therapy is the woman who is asymptomatic, motivated, and compliant, with.

Success rate depends on

• Initial serum  Beta hCG level,

Success rate is 1.5 percent if the initial serum hCG concentration was <1000 mIU/mL;5.6 percent with 1000-2000 mIU/mL; 3.8 percent with 2000-5000 mIU/mL;

and 14.3 percent when levels were between 5000 and 10,000 mIU/mL

• Ectopic pregnancy size

93-percent success rate with single-dose methotrexate when the ectopic mass was <3.5 cm, compared with success rates between 87 and 90 percent when the mass was >3.5 cm.

Fetal cardiac activity -relative contraindication to medical therapy

 Rupture of Persistent Ectopic Pregnancy–

This is the worst form of primary therapy failure with a 5 to 10-percent occurrence in women treated medically.

Expectant Management

Tubal ectopic pregnancies only

Decreasing serial  – BHCG levels

Diameter of the ectopic mass not >3.5 cm

No evidence of intra-abdominal bleeding or rupture by transvaginal sonography

Resolution without treatment was more likely if the initial serum  -hCG level was <1000 mIU/mL.

Surgical Management

Laparoscopy

Laparotomy

References

1. F. Gary Cunningham, Kenneth J. Leveno,et al, Williams Obstetrics, 22edition, Section III, chapter10.

About the Author:

Author

Dr Pratiksha Gupta

Associate Professor

Department of Gynecology and Obstetrics

PGIMSR,ESIC,

Basaidarapur

New Delhi

Corresponding author

Dr Pratiksha Gupta

House number 11284 Laj building

No 1, doriwalan new rohtak road

Karol baghNew delhi110005

Mobile no. 09871128703

Email-  drpratiksha@gmail.com