Medgate today Magazine May-June, 2010 by Medgate Today Magazine

NEWS l DOCTOR SPEAK l SPECIAL FEATURE l BEAUTY & COSMETIC l LIFE GUARD l ACUPUNCTURE

Vol.I Issue 1

May-June 2010

Gateway to Health & Medical World

exposure of

TOOTH Health &

fitness Expert

M E D G AT E T O D A Y R S 7 5

VIEWS

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EDITOR

SPEAK

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ello and welcome once again to Medgate Today Magazine. I would like to open this issue of the Magazine by thanking all of you. The Publication has been nothing

short of fantastic and we are grateful for the opportunity to continue bringing important health advice and information to all. Medgate Today provides an insight into this challenging condition with an overview of the spectrum. We also look at a luxury treatment method that is helping to heal. This issue also focuses on the other medical and health industry to take insight of the current scenario and future prospective, we feel passionate about the feedback from our readers. We hope that you find this latest addition of Magazine useful and we welcome your comments and opinions on the magazine. Any thoughts or question you may have mail us: info@medgatetoday.com

Dr M A KAMAL Editor-in-chief

2 MAY-JUNE l 2010

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CONTENTS 12

06 News Jordanian organ trafficking suspect held in Yemen Simple eye test can detect mental disorders

12 Cover Story Designed to heal

18 Product Line Medical Equipment

20 Dental Hygien Brushing Technique

23 Beauty & Cosmetic Acne Vulgaris How to Look Younger

29 Doctor Speak Chest pain

30 Health & fitness How much weight women shousld gain during pregnancy Healthy Orange 4 MAY-JUNE l 2010

Volume I Issue 1

EDITOR Dr. M. A. Kamal EDITORIAL ADVISOR Dr. N. Ashraf Dr. Shakilur Rahman Dr. S.L. Shah Dr. Firozuddin Faiz CHIEF CORRESPONDENT S. A. Rizvi Dr. H. N. Sharma DESIGN BY Studio Design CREATIVE DESIGNER Nitu Sinha

40 Expert Views

GRAPHIC DESIGNER Amit Kumar

Arthritis cause & Treatment Merging Talents with Technology

SALES & MARKETING Amjad Kamal Abrar Ahmad Jawaid Devendra Kumar Yadav Kashif Saigal S. Firoz Rahul Ranjan SUBSCRIPTION & CIRCULATION Pallavi Gupta All rights reserved by all everts are made to ensure that the information published is orrect, MEDGATE TODAY holds no responsibility any unlikely errors that might occur.

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48 Special Features Doctor appearance

52 Life Guard An Emergency Oxygen Guideline

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NEWS

UPDATE

Jordanian organ trafficking suspect held in Yemen

SANAA - A Jordanian suspected of trafficking in human organs has been arrested in Yemen as he attempted to fly to Egypt along with seven of his “victims,” the interior ministry said on its website . “Security forces in the capital arrested a Jordanian organ trader named Ramzi Khalil Abdullah Farah who was trying to travel to Egypt along with

6 MAY-JUNE l 2010

seven Yemeni victims,” the ministry said. It said Farah was wanted for allegedly recruiting people to sell their kidneys. It said the seven Yemenis, aged between 20 and 45, were “on their way to Egypt after being persuaded by the Jordanian trader” who advanced them money from the proposed sale of their organs. The ministry website did not say how much was reportedly paid to each person. Yemen is the poorest country in the Arab world. The World Health Organisation considers Egypt, where hundreds of poor people sell kidneys or parts of their livers every year, to be a centre for organ trafficking. Parliament in Cairo adopted a law to regulate organ transplants and limit trafficking in late February. According to the United Nations, hundreds of poor Egyptians sell their kidneys and livers every year to buy food or pay off debts. MT

NEWS

UPDATE

Simple eye test can detect mental disorders A SIMPLE eye test can help diagnose inherited mental health conditions such as bipolar disorder or manic depression, according to new evidence. Monash University neuroscientist Steven Miller led a national team of researchers to test the binocular rivalry rates of 348 sets of twins -- 128 of whom were identical. The test measured the twins’ binocular rivalry—the ‘switching’ of their visual perception from one image to the next, when two dissimilar images were simultaneously presented one to each eye. Miller’s study of twins showed that switching rates were very similar between each set of identical twins, yet were substantially less so for non-identical twins, suggesting a genetic contribution to an individual’s switching rate. ”By studying such a large group of identical and non-identical twins we can determine the likelihood of genetics being responsible for certain biological traits,” Miller said. Miller said testing of binocular rivalry was impor-

tant because it could be an indication of a person’s mental health, based on his previous study of switching rates in patients with bipolar disorder. ”A person without bipolar disorder will make the switch between images every one to two seconds. However, a person with bipolar disorder takes three to four seconds, and up to 10 seconds, to switch between the images,” Miller said. ”These results highlight the link between our genetic makeup and the manifestation of certain medical illnesses like bipolar disorder.” The next stage of the research would test the reliability of using the switch rate to assist in the diagnosis of bipolar disorder or a predisposition to bipolar disorder, said a university release. ”There is a lot of work ahead to find biological markers that could be used to screen for a person’s susceptibility to a particular inherited condition, paving the way for more accurate clinical diagnoses and more effective genetic studies,” Miller said. MT

MAY-JUNE l 2010

NEWS

UPDATE

Cancer, infection seen with Novartis, Astellas drugs WASHINGTON: Novartis AG and Astellas Pharma eczema drugs may need their warning labels expanded after dozens of new reported cases of cancer and infection in children, US Food and Drug Administration staff said in documents released on Thursday. Agency scientists said 46 cancer cases and 71 infection cases have been reported in patients aged 16 and younger from 2004 to 2008 with Novartis' Elidel and Astellas' Protopic. Both drugs - also known as pimecrolimus and tacrolimus respectively - already carry strong warnings about cancer and infection, but officials should consider expanding them to include the new postmarketing reports, they wrote. The documents were released ahead of an FDA advisory meeting Monday to weigh potential safety concerns with a variety of drugs used in younger patients. Additionally, other FDA staffers said the warning label for GlaxoSmithKline Plc's herpes drug Valtrex was "insufficient" for certain central nervous system side effects in children, although no other concerns were seen. Another scientist noted concerns about the use of Pfizer Inc's antibiotic Zmax in pregnant women and the potential for it to cause stomach blockages in newborns. The FDA will weigh the recommendations from its panel of outside advisers before taking any action. It was not clear what staff reviewers thought about the weight-loss drug orlistat, marketed as Glaxo's Alli and Roche Holding AG's Xenical. No new safety concerns were seen with other drugs to be discussed at the meeting, FDA staff said. MT

8 MAY-JUNE l 2010

Those drugs include: • L'Oreal sunscreen ingredient Anthelios 40 • DuPont imaging agent Cardiolite (technetium Tc-99) • Sanofi-Aventis allergy drug Nasacort AQ (triamcinolone); five-disease vaccine Pentacel; diphtheria, tetanus and pertussis vaccine Daptacel • Privately held Boehringer Ingelheim's HIV drug Viramune (nevirapine) • Glaxo's rotavirus vaccine Rotarix; diphtheria, tetanus and pertussis vaccine Kinrix

NEWS

UPDATE

Early detection of complications after Gastrostomy GASTROSTOMIES are used as a medium to long term feeding strategy for children and adults with additional dietary needs or an inability to swallow, and they may be inserted surgically, endoscopically, or under radiological guidance. About 15 000 gastrostomies are inserted annually in the United Kingdom. Complications include chemical peritonitis, infection, bowel perforation, haemorrhage, and aspiration pneumonia. But early recognition and prompt action reduces the risk of serious harm or death. Over six years (October 2003 to January 2010) the National Patient Safety Agency (NPSA) received 22 reports (including five incidents in children) from clinical staff of harm from delayed response to serious complications after gastrostomy insertion. Eleven patients died and 11 became critically ill. Reported complications included nine cases of leakage of feed into the peritoneal cavity and/or peritonitis, three colonic punctures, and two complications related to haemorrhage; under-reporting is likely. surgical creation of an artificial opening into the stomach through the abdominal wall. It is per-

formed to prevent malnutrition and starvation in patients who have esophageal cancer or tracheoesophageal fistula, who may be unconscious for a prolonged period, or who are unable to swallow as a result of a cerebrovascular accident, Alzheimer's disease, or another disorder. It also permits retrograde dilation of an esophageal stricture. The anterior wall of the stomach is drawn forward and sutured to the abdominal wall. A Foley catheter or other tube or a special prosthesis is then inserted into an incision in the stomach, and the opening is tightly sutured to prevent leakage of the stomach contents. The device is clamped and is opened when liquid food supplement is instilled. After surgery glucose water may be given, followed by a slow continuous feeding of a warm blended formula to increase absorption. The skin is kept clean and dry around the site. Skin irritation indicates leakage of gastric secretions and digestive enzymes. MT

Viral agenda on WHO Assembly THE WORLD Health Organization is being urged to step up the fight against viral hepatitis and develop a comprehensive approach to its prevention and treatment, with a resolution on the disease to be presented to the 63rd World Health Assembly later this month. This will be the first time that the assembly has considered viral hepatitis, despite the huge burden of disease worldwide, said Steven Wiersma, medical officer and hepatitis focal point at WHOâ&#x20AC;&#x2122;s headquarters in Geneva. "One in 12 people in the world are chronically infected with hepatitis B [and] the burden is extraordinarily high, yet somehow itâ&#x20AC;&#x2122;s been left off the worldâ&#x20AC;&#x2122;s public health agenda," he said. WHO is already active in preventing viral hepatitis by promoting immunisation and educating on blood and injection safety, but no comprehensive plan and no programmes for people who are chronically infected exist.

10 MAY-JUNE l 2010

NEWS

UPDATE

Govt declares breast cancer drug Albupax sub-standard ALBUPAX, A DRUG used in the treatment of breast cancer, has been declared as sub-standard by the Government due to the presence of certain particles beyond the acceptable limits. The Central Drug Laboratory, Kolkata, in its test report has declared the drug "to be not of standard quality" due to the presence of higher level of Endotoxin than acceptable limits, Health Ministry sources said. Albupax is the first generic version of the international brand ? Abraxane of Abraxis BioSciences, USA. It has been indigenously developed by a company in India and is the first albumin bound Paclitaxel in nanoparticle to be developed in the country.

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Designed to

Can a painting on a wall or classical music in the background reduce recovery time for a hospitalised patient? says Afzal kamal VERY soon, every single establishment will parade as a hotel industry unit. It’s bad enough that regular spaces such as salons and banks imitate hotel-spa concepts, but now hospitals too seem to be following suit. But when it comes to medical institutions catching up with this trend, you cannot take it at face value – for good reason, really. The little touches of the Leonardo da Vinci painting on the wall, the natural window views and maybe Beethoven’s Ninth Symphony or Pavarotti in the background in your average hospital room, could potentially reduce recovery time. In other words, these décor changes (well, maybe not as grand as a da Vinci painting) go beyond the adage of old content in new packaging. The nub of healthcare design is to make a patient feel better – faster.

MAY-JUNE l 2010

COVER

STORY

A quick sweep through scientific data to establish the link between design and patient benefits reveals that research is nascent. Still, it is hard to ignore what is increasingly becoming the norm of a hospital’s functioning – ambient facilities and hospitality. The former feature has hospitals going the extra mile to create a comfortable and pleasant atmosphere. Some do this by positioning pieces of art and sculpture, others by designing the room around views of nature, and yet others by doing something as simple as carpeting an area to minimise noise.

INNOVATIVE AMBIENT CONCEPTS Healthcare architects, designers and space planners – as they are called – have introduced innovative design concepts ranging from the expected to the unheard of. They not only consider the R&D aspect of these design technologies, they study the healing impact of factors such as room size and scale, privacy, lighting, ventilation, the colour of walls and furnishings, fabrics, art, music and views.

14 MAY-JUNE l 2010

COVER

STORY In fact, hospitals themselves evaluate the healing impacts, says Amer Salha, the head of Medical Equipment Planning at the American Hospital in Dubai. “The evaluation plays a major role in reviewing current services and planning modifications, and considers the future expansion [of the hospital]. In general, hospitals are aware of the benefits of improved surroundings and pay more attention to patient experience,” he says. A few findings validate how changes in décor reduce recovery time for a hospitalised patient. Notably, findings from the Johns Hopkins University that conducted a comprehensive review of 84 studies on the impact of health to demonstrate that the mind, brain and nervous system can be directly influenced positively or negatively by elements in the environment. Further validation comes from a study conducted by Marina de Tommaso and a team from the University of Bari in Italy; they highlighted the aesthetic value of paintings on pain thresholds. Music also forms a part of ambient facilities and the right kind is known to have a positive effect on patients. Studies from Pavia University in Italy showed that listening to certain genres can slow the heartbeat and lower blood pressure. But regardless of what a hospital may choose to aesthetically improve its surroundings, the result is positive: the patient feels better and the hospital stands to benefit in terms of a shorter length of stay, and hence, lower cost per case. “A hospital’s rating is directly tied with its sur-

MAY-JUNE l 2010

COVER

STORY

gical outcomes and the length of stay; the shorter the stay, the higher the rating,” Administration manager Garreth Estment from The City Hospital in Dubai, which won the Best Interior Design Award at the Hospital Build Awards Middle East last year, agrees. He says, “If you think about it, a nice and comfortable place makes you relax. It also creates a positive frame of mind and thereby assists with the healing process.” In the UAE, an example of this trend is the ambient cardiac catheterisation laboratory at the Sheikh Khalifa Medical City (SKMC) in Abu Dhabi. It has been designed with scene projectors, special lighting and sound effects – all targeted at optimising patient care. And more importantly, it has been clinically proven to reduce anxiety. However, aesthetic features by themselves aren’t enough. Functionality is just as important. There should be a balance, says Estment. “No amount of pleasant aesthetic surroundings can dispel the anxiety of a clinical area if it isn’t functional.” In the same vein, ambient facilities need to be customised because they do not provide a onesize solution.

DIFFERENT PROBLEMS, DIFFERENT SOLUTIONS Ambient facilities need to be tailored according to whether it’s psychiatric, geriatric or postoperative care. Patients have different needs – whether it is lighting or furniture. Salha says, “In the psy-

16 MAY-JUNE l 2010

chiatric ward for example, we need to choose furniture to ensure that the patient doesn’t injure himself. Whereas in the geriatric ward, we have to choose beds with special pressure mattress to avoid bed ulcers.” Healthcare design has to look at patients’ needs and how they react to different stimuli. “Each unit needs to be suited to a specific medical speciality and the patient’s individual needs,” says Estment. Take lighting for example. A study from the USbased Lighting Research Center (LRC) shows how innovative lighting designs and advanced technologies, including LEDs, photosensors and occupancy sensors, can help seniors in long-term care environments maintain independence and be more comfortable. There are several other areas where the right lighting can reduce the recovery period. According to Estment, these areas include ophthalmology, maternity wards, delivery rooms, paediatric wards and dialysis units. Salha adds: “Lighting is an important consideration in the psychiatric and geriatric wards too. It [lighting selection] is crucial to create the effect of day and night for patients who are required to get rest or vice-versa.”In addition to aesthetic features, hospitals are also working towards providing upto-date entertainment systems, internet connectivity and a host of other amenities in the hope that patients will enjoy their stay and leave as soon as they feel well enough to do so. MT

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PRODUCT

LINE

MEDICAL AND DENTAL equipment is designed to aid in the diagnosis, monitoring or treatment of medical conditions. These devices are usually designed with rigorous safety standards. The medical equipment is included in the category Medical technology.

There are several basic types: ●

● ●

●

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Diagnostic equipment includes medical imaging machines, used to aid in diagnosis. Examples are ultrasound and MRI machines, PET and CT scanners, and x-ray machines. Therapeutic equipment includes infusion pumps, medical lasers and LASIK surgical machines. Life support equipment is used to maintain a patient's bodily function. This includes medical ventilators, anaesthetic machines, heart-lung machines, ECMO, and dialysis machines. Medical monitors allow medical staff to measure a patient's medical state. Monitors may measure patient vital signs and other parameters including ECG, EEG, blood pressure, and dissolved gases in the blood. Medical laboratory equipment automates or helps analyze blood, urine and genes. Diagnostic Medical Equipment may also be used in the home for certain purposes, e.g. for the control of diabetes mellitus A biomedical equipment technician (BMET) is a vital component of the healthcare delivery system. Employed primarily by hospitals, BMETs are the people responsible for maintaining a facility's medical equipment

MAY-JUNE l 2010

DENTAL

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Brushing

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1 Clean the outside of all upper teeth with short, gentle, vibratory, back and forth strokes paying special attention to the areas where teeth and gums meet.

2 Clean the inside surface of all upper teeth with the same short, gentle, vibratory back and forth strokes. 20 MAY-JUNE l 2010

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DENTAL

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3 Repeat vibratory back and forth strokes on the outside and inside surfaces of all upper and lower teeth.

4 Cleaning the inner surfaces of both the upper and lower teeth is easier when the brush is tilted.

5 Brush the biting surface of both upper and lower teeth with short gentle, vibratory, back and forth strokes.

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BEAUTY &

COSMETIC

ACNE VULGARIS is the most common form of acne. It is considered an abnormal response to normal levels of the male hormone testosterone. The response for most people diminishes over time and acne thus tends to disappear, or at least decrease, after one reaches their early twenties. There is, however, no way to predict how long it will take for it to disappear entirely, and some individuals will continue to suffer from acne decades later, into their thirties and forties and even beyond. It includes several types of pimples. These acne lesions include blackheads, whiteheads, papules, pustules, nodules and cysts. Mild to Moderate acne vulgaris consists of the following types of acne spots:

● WHITEHEADS ● BACKHEADS ● PAPULES Whiteheads: Whiteheads are formed when a pore is completely blocked, trapping sebum (oil), bacteria, and dead skin cells, causing a white appearance on the surface. In other words, Whiteheads are a combination of oils, sebum and cellular fragments that produce firm to hard plugs within hair follicles. They are closed from the skin's surface by cellular debris at the follicle opening. Because they have no contact with oxygen, they do not oxidize or turn brown, as blackheads do. They form a light or yellow-white lump and are called milia (or milium, singular). When bacteria is added to these plugs, the condition can lead to acne, especially cystic acne.Whiteheads are promoted by excessive cellular exfoliation, which quickly clog or block the follicles. Some skin specialists believe individuals with frequent and multiple blackheads and whiteheads produce sebum that is drier than normal and conducive to forming firm plugs. Whiteheads are normally quicker in life cycle than blackheads

Acne Vulgaris MAY-JUNE l 2010

BEAUTY &

COSMETIC

Blackheads: These appear when a pore is only partially blocked, allowing some of the trapped sebum (oil), bacteria, and dead skin cells to slowly drain to the surface. The black color of a black head is caused by reaction of the skin's own pigment, melanin, reacting with the oxygen in the air. A blackhead is much more stable than a white head and takes a long time to clear. When bacteria is added to black heads, the condition can lead to acne Papules: Dermatologists call any small solid circumscribed bump in the skin a papule, as opposed to a vesicle which contains fluid or a macule which is flat and even with the surrounding skin. Papules are normally inflamed, pink or red in color. Squeezing a papule is not recommended as it might lead to scarring Severe acne vulgaris results in:

● NODULESM ● CYSTS Nodules: As opposed to the lesions mentioned above, nodular acne consists of acne spots which are much larger, can be quite painful and can sometimes last for months. Nodules are large, hard bumps under the skin's surface. Scarring is common. Absolutely do not attempt to squeeze such a lesion. You may cause severe trauma to the skin and the lesion may last for months longer than it normally would. Dermatologists often have ways of lessening swelling and preventing scarring. Cysts: An acne cyst can appear similar to a nodule, but is pus-filled, and has been described as having

24 MAY-JUNE l 2010

a diameter of 5mm or more across. They can be painful. Again, scarring is common with cystic acne. Squeezing an acne cyst may cause a deeper infection and more painful inflammation which will last much longer than if you had left it alone. Dermatologists often have ways of lessening swelling and preventing scarring. Acne Rosacea can look similar to the aforementioned acne vulgaris, and the two types of acne are sometimes confused for one another. Rosacea affects millions of people, generally females above the age of 30. It affects the middle third of the face, and symptoms include skin redness and swelling in the areas that typically flush when we’re excited or embarrassed; telangiectases (the appearance of broken blood vessels), and, occasionally, acne-like papules and pustules. For this reason, rosacea is often misdiagnosed as acne and treated with acne medications. Without appropriate medical treatment Rosacea can cause swelling of the nose and excessive tissue growth resulting in a condition known as Rhinophyma. Rosacea tends to be more frequent in women but more severe in men. If you think you may have rosacea, see a dermatologist right away. While there is no known cure for this condition, it is treatable – and early treatment will help prevent permanent damage to your skin. Acne Mechanica is the acne that develops when skin is under pressure, is undergoing friction, is covered tightly or is exposed to heat.

BEAUTY &

COSMETIC Some situations when Acne Mechanica may form areTight clothing that rubs against the skin, Synthetic clothing that does not allow skin to breathe, Pressure of backpacks. Some examples of such pressure that may cause acne mechanica arePoeple carrying backpacks, athletes wearing a tight headband, women wearing bras with tight straps etc. Any situation during which the skin is tightly covered with cloth, rubbed and pressurized makes it vulnerable to acne mechanica. For example- people who wear very tight clothes made of synthetic material may get acne mechanica. Who are more prone to acne mechanica? Those who have a tendency to develop body acne are more prone to acne mechanica. Those with very small comedones are prone to it. When these small comedones are subjected to mechanical pressure and friction, they flare up as acne mechanica. The treatment of acne mechanica is similar to that of Acne vulgaris. To learn more about acne treatments, click here - Acne Treatments. To Avoid Acne MechanicaWear loose fitting cotton clothing, Avoid headbands, Avoid constant pressure on the skin by any object, Keep skin clean of perspiration. Wearing cotton clothes that breathe under your regular clothes may help. Washing yourself thoroughly after removing the irritating baggage/object may help. Severe Forms of Acne are rare, but they are a great hardship to the people who experience them, and can be disfiguring and, like all forms of acne, can have psychological effects on the sufferer. Severe forms of acne comprise of:

● ● ● ●

ACNE CONGLOBATA ACNE FULMINANS GRAM-NEGATIVE FOLLICULITIS PYODERMA FACIALE

Acne Conglobata: This is the most severe form of acne vulgaris and is more common in males. It is characterized by numerous large lesions, which are sometimes interconnected, along with widespread blackheads. It can cause severe, irrevocable damage to the skin, and disfiguring scarring. It is found on the face, chest, back, buttocks, upper arms, and thighs. The age of onset for acne conglobata is usually between 18 and 30 years, and the condition can stay active for many years. As with all forms of acne, the cause of acne conglobata is unknown. Treatment usually includes isotretinoin , and although acne conglobata is sometimes resistant to treatment, it can often be controlled through aggressive treatment over time. Acne Fulminans: This is an abrupt onset of acne conglobata which normally afflicts young men. Symptoms of severe nodulocystic, often ulcerating acne are apparent. As with acne conglobata, extreme, disfiguring scarring is common. Acne fulminans is unique in that it also includes a fever and aching of the joints. Acne fulminans does not respond well to antibiotics. Isotretinoin and oral steroids are normally prescribed. Gram-Negative Folliculitis: This condition is a bacterial infection characterized by pustules and cysts, possibly occurring as a complication resulting from a long term antibiotic treatment of acne vulgaris. It is a rare condition, and we do not know if it is more common in males or females at this time. Fortunately, isotretinoin is often effective in combating gram-negative folliculitis. Pyoderma Faciale: This type of severe facial acne affects only females, usually between the ages of 20 to 40 years old, and is characterized by painful large nodules, pustules and sores which may leave scarring. It begins abruptly, and may occur on the skin of a woman who has never had acne before. It is confined to the face, and usually does not last longer than one year, but can wreak havoc in a very short time. MT By Dr. Piyush Pankaj

MAY-JUNE l 2010

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INTERVIEW

Protect yourself from sun and tanning studio's. The sun and tanning studio's are the main reasons for premature aging. By applying self tan spray or keeping your face well protected from UV rays can help to prevent premature aging.

Keep up regular exercise. Regular exercise helps to keep the skin elasticity which prevents wrinkles. Exercise is also good for your body as a whole as it helps to maintain a low amount of body fat.

Taking vitamins and minerals helps to keep goodness in the skin. Vitamins and minerals have been developed to help your body. By taking one multivitamin can help to keep your skin fresh and clean.

Dr. PIYUSH DR.PIYUSH, Healthy, younger looking skin is what everyone dreams of, Could you tell us some tips to maintain out skin healthy and younger? WELL, Healthy, younger looking skin is not hard to achieve. Looking after your appearance and maintaining a regular routine and healthy diet can help to give you perfect looking skin, free from spots and blemishes.

10 TIPS THAT WILL HELP YOU ON YOUR WAY TO BEAUTIFUL SKIN.

Your outside appearance reflects what's on your inside. Maintain a healthy and balanced diet with plenty of fruits, vegetables ,Green salads and sunflower seeds.

Try and drink 6 to 8 glasses of water per day. This will help to keep your skin moist, refreshed and supple, which will help the skin fight off developing wrinkles and blemishes.

Moisturize! Applying moisturizer after a warm face wash or a warm shower is the best remedies for skin. Moisturizing helps to restore the oils that our skin has and helps to keep the skin hydrated. Moisturizing for men is just as important as the oils in men's skin can be lost more easily than those in women.

28 MAY-JUNE l 2010

Try and maintain a constant sleep pattern. Sleep is the body's time to restore itself and to re-energise the body's organs and skin. By maintaining a regular sleep pattern, you will feel more energized and your skin will become more healthy and fresher looking.

Do not scrub and wash too hard. By doing this it removes the required oils that the skin needs to regenerate. When washing, wash lightly and in circular motion. This helps to keep the blood flow in your skin and does not allow the essential oils to escape.

Do not squeeze Acne. Although very tempting, by squeezing white heads and black heads, the disease spreads and your acne will not disappear. By not squeezing your skin can heal the acne on its own and scars will not be formed. Constant squeezing of acne will cause scarring of the skin.

Finally, the most important thing you can do to help achieve, younger healthier looking skin is to stop smoking or never to start. Smoking causes premature aging and yellowing of the teeth and skin. The tobacco that is released into the air dries out your skin, while the smoke you inhale constricts the flow of blood to blood vessels, therefore preventing your skin of essential nutrients that your body supplies.MT

DOCTOR

SPEAK

CHEST PAIN

Is it my heart pain? CHEST PAIN accounts for up to 10% of new complaints at internal medicine outpatient clinics and for up to 8% of all emergency department visits. Despite this prevalence, and that of coronary artery disease (CAD), diagnosis is often difficult. Although over 80% of outpatients presenting with chest pain proceed to diagnostic testing, only one third subsequently prove to have had a myocardial infarction, while 1% to 8% of those with myocardial infarction confirmed by cardiac enzyme levels are misdiagnosed and discharged home. The first diagnostic step is to take a careful history.

ment and T-wave changes consistent with myocardial ischemia favor the diagnosis of angina. Q waves indicative of previous myocardial infarction also increase the likelihood of CAD, although an isolated Q wave in lead III or a QS pattern in leads V1 and V2 is often nonspecific. During chest pain the ECG becomes abnormal in half the angina patients with a normal resting ECG. Sinus tachycardia is common, Brady arrhythmia less so. Other indicators are ST-segment and T-wave depression or inversion on the resting ECG and their pseudo normalization

TYPICAL ANGINA IS CHARACTERIZED BY: ●

Risk factors (smoking, diabetes, hypertension, hyperlipidemia, family history of CAD) ● Location (mid Retrosternal and/or radiating to left arm, throat, jaw, epigastrium, right arm) ● Quality (tight, squeezing, constricting, suffocating, burning, crushing, heavy) ● Duration (minutes) ● Mode of noset (physical or emotional stress) Mode of relief (rest or sublingual nitrates). Where the history is insufficient on its own, physical examination and noninvasive tests aid the diagnosis. Althought physical findings are often normal in stable angina, S4 or S3 gallop may be detected during a bout of pain, along with a mitral regurgitant murmur, paradoxically split S2, bilateral basal rales, or chest wall heave. Each such finding makes CAD more likely, especially if it disappears when the pain subsides. Similarly, evidence of noncoronary atherosclerotic disease, such as a carotid bruit, diminished pedal pulses, or an abdominal aneurysm, also increases the likelihood of CAD. Other physical markers of risk factors include elevated blood pressure, xanthoma, and retinal exudates. The two main noninvasive tests are electrocardiography (ECG) and echocardiography. Since 12lead ECG is normal in 50% of patients with chronic stable angina, it cannot exclude CAD. However, evidence of left ventricular hypertrophy or ST-seg-

during pain. As for echocardiography, wall motion abnormalities and a low ejection fraction increase the probability of CAD. The clinician suspecting CAD should estimate its probability, given that pretest probability determines the accuracy of the standard exercise test as a first-line diagnostic procedure. Chun et al described the effect of pretest probabilities varying from 5% to 50% to 90%: a low probability of CAD (5%) confers a dramatically low positive predictive value (21%) on an abnormal test. With an intermediate probability (50%), a positive test result increases the likehood of CAD to 83%, while a negative test result decreases the like hood to 36%. In patients with ahigh probability (90%), a positive test result raises the probability of CAD to 98%, while a negative test results carries accurate negative predictive value. MT

MAY-JUNE l 2010

How much weight women should gain during — Surprisingly little if they’re already overweight.

HEALTH &

FITNESS EATING FOR two? New guidelines are setting how much weight women should gain during pregnancy — surprisingly little if they’re already overweight. The most important message: Get to a healthy weight before you conceive, says the Institute of Medicine in the first national recommendations on pregnancy weight since 1990. It’s healthiest for the mother — less chance of pregnancy-related high blood pressure or diabetes, or the need for a C-section — and it’s best for the baby, too. Babies born to overweight mothers have a greater risk of premature birth or of later becoming overweight themselves, among other concerns. Meeting the guidelines could be a tall order, considering that about 55 percent of women of childbearing age are overweight, that preconception care isn’t that common and about half of pregnancies are unplanned.Once a woman’s pregnant, the guidelines issued on Thursday aren’t too different from what obstetricians already recommend, although about half of women don’t follow that advice today.

AMONG THE NEW RECOMMENDATIONS: ●

A normal-weight woman, as measured by BMI or body mass index, should gain between 25 and 35 pounds during pregnancy. A normal BMI, a measure of weight for height, is be-

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HEALTH &

FITNESS tween 18.5 and 24.9. An overweight woman — BMI 25 to 29.9 — should gain 15 to 25 pounds during pregnancy. ● For the first time, the guidelines set a standard for obese women — BMI of 30 or higher: 11 to 20 pounds. ● An underweight woman — BMI less than 18.5 — should gain 28 to 40 pounds. What if a mom-to-be has gained too much? On average, overweight and obese women already are gaining five more pounds than the upper limit. But pregnancy is not a time to lose weight, “It’s not, ‘Hey you gained enough, now you need to stop,’” Siega-Riz said. “Let’s take stock of where you’re at and start gaining correctly.” Indeed, underweight and normal-weight mothers should put on a pound a week for proper fetal growth in the second and third trimesters, the guidelines say. The overweight and obese need about half a pound a week. Hopping on the scale during prenatal checkups makes for a sensitive moment, especially in a culture that cherishes the stereotype of late-night ice cream-and-pickles snacks. Implementing the guidelines may take a move “to change the whole culture about pregnancy” and eating, Siega-Riz said. She noted that in studies of the overweight, “most of these women will tell you that they’ve never been told how much weight to gain.” The guidelines call for increased nutrition and exercise counseling during pregnancy, saying doctors or midwives may need to consult a dietitian to tailor a woman’s care no matter her starting weight. Also, providers should discuss whether a woman plans to breastfeed, which not only is optimal for the baby but helps the new mother shed pounds, too. “It’s really a teachable moment,” said guidelines co-author Dr. Patrick Catalano, obstetrics chairman at Ohio’s Case Western Reserve University. “When women are pregnant, they may be more accepting” of weight discussions “because it’s also in the best interest of their babies.” Obstetricians, who have struggled with how to advise heavier women as U.S. obesity rates have soared over the past two decades, welcomed the guidelines — especially the recognition that babies born too large tend to grow into overweight children at risk for their own health problems. Not too many years ago it was rare to see a 9-pound, or larger, newborn. ●

32 MAY-JUNE l 2010

“Pregnant women should not be eating for two,” said Dr. Ellen J. Landsberger, who specializes in high-risk pregnancies at New York’s Montefiore Medical Center. “You want a healthy baby? On both ends, you have to eat the right amount.” But is it realistic for obese women to gain as little as 11 pounds? “We think it’s possible. We also think it will be a challenge,” said Cornell University nutrition specialist Dr. Kathleen Rasmussen, who chaired the Institute of Medicine committee. In the Bronx, Nyree Paten illustrates that challenge: She had been putting on weight for three years and discovered she was pregnant at her peak, just over 300 pounds, seriously obese even for someone 6 feet tall. Her doctor diagnosed diabetes at her first prenatal checkup. Landsberger found Paten, 35, a nutritionist and prescribed insulin for the diabetes. Paten said she’s gained only about 2 pounds by week 24, while regular ultrasounds show her baby is growing well. “Thank God I’ve been doing good,” says Paten, who feels more energetic because she’s eating better. So is her 8-year-old son. First to go: sugary sodas and juices in favor of water. “It’s all about knowing and being educated on how to eat,” adds Paten, who’s lined up the nutritionist to help her lose weight once her baby is born. The guidelines say women expecting twins can gain more: 37 to 54 pounds for a normal-weight woman, 31 to 50 pounds for the overweight, 25 to 42 pounds for the obese. There’s not enough information to set recommendations for triplets or more. The institute stressed that the guidelines are aimed at U.S. women, not for parts of the world with different nutritional and obstetric needs.MT

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BEAUTY &

COSMETIC

acupuncture

effective or not?

34 MAY-JUNE l 2010

BEAUTY &

COSMETIC LIKE MASSAGE, acupuncture is difficult to study because it’s hard to give a “fake” massage or “placebo” acupuncture. Says Clauw: “In ‘sham’ or placebo controlled trials in chronic pain, more studies have shown that acupuncture doesn’t work. But that doesn’t necessarily mean that it’s not effective— it might be that there really is no such thing as sham acupuncture. Acupuncture might somehow be effective in engendering a placebo response.” Whether that matters if someone feels significant pain relief is a question only the patient can answer. “The best evidence that it’s effective is that a lot people will pay out of pocket to use it,” he says. Clauw himself conducted a fascinating imaging study of acupuncture, finding that while patients with fibromyalgia reported decreased pain with both fake and real acupuncture, fake acupuncture affected brain opioid receptors in a way that was more comparable to that seen with placebo. “Sham acupuncture may work via placebo effects and active acupuncture may work by more specific effects. That could help explain why trials don’t show much difference,” he says. Some have claimed that electroacupuncture— which runs a small current through acupuncture needles—is more effective than needles alone, but Clauw says it’s even harder to parse out placebo effects here. “It may give a stronger placebo effect,” he says. For people in pain, however, that could be a good thing.MT

MAY-JUNE l 2010

HEALTH &

FITNESS

Healthy orange YOU MUST be surprised that the common low-cost orange, available in every market, is a star among the twenty fruits (mango, fig, orange, strawberry, goji, red grape, cranberry, kiwifruit, papaya, blueberry, sweet and sour cherries, red raspberry, seaberry, guava, blackberry, black currant, date, pomegranate, acai, and plums) chosen by Dr. Paul Gross to be superfruits. Even though the orange ranks number three, in reality it ties up with the fig, The orange is cultivated in many parts of the world, South-East Asia, the Middle East, Africa, Brazil, and the United States. Orange juice is the only superfruit product traded on the New York Stock Exchange as a commodity in worldwide trading. Orange juice is also the most popular among all juices. It is served freshly squeezed or canned in parties, for breakfast, at receptions, and in homes and restaurants. Availability in stores and low cost make the high nutritional value of the orange and juice accessible to a good section of the world population. The orange, Citrus sinensis, is a member of the citrus family (lemon, lime, grapefruit, tangerine, mandarin, kumquat). The fruit itself comes in different varieties and diversity in tastes and has multiple uses. Its variations range from navel orange, Persian, blood, and cara cara navel to tangerine and

36 MAY-JUNE l 2010

mandarin. Orange pulp is not the only part of the fruit, which is healthy, but also the fleshy white substance, pith, surrounding the pulp and the segments. The pith is where the prebiotic (soluble) fiber and bioflavonoids are found. Citrus bioflavonoids are the most bioavailable to the body. The fruit offers hearthealthy pectin (apples have it, too) and polysaccharides. The healthful fiber of the fruit works to protect the body from cancer and blood vessels from cholesterol buildup. That is not all! There is more to this superfruit. Orangeâ&#x20AC;&#x2122;s merits led it to be named superfruit. It contains most essential nutrients needed to maintain good health. The fruit and its peel are rich in vitamins A (through its precursor beta-carotene), Bs, and C, important minerals, both soluble and insoluble fiber, and phytochemicals like carotenoids and polyphenols in the deep orange pigment. The fruit is rich in iron for preventing anemia and calcium for building bone. The peel and zest are employed for making gravy, marmalade, desserts to garnish and add zest. They help breakdown fat in food (duck a la orange). Eating a whole fruit after a fatty meal breaks down fat. Niacin, vitamin B3, is abundant in the fruit; it protects the heart.

HEALTH &

FITNESS Freshly squeezed orange juice has become a universal breakfast staple. It provides a good concentration of necessary nutrients (vitamins A, Bs, and C), especially if loose bits of the pulp and fiber are left inside the juice for extra nutrients, texture, and flavor. For maximum benefit, drink orange juice immediately before the nutrients start breaking down. All oranges are not equal in phytochemicals. Though they all contain polyphenols, the blood orange with its red pulp is higher in anthocyanins and lycopene. The flavonoid, hesperidin, is found in the flesh, but moreover in the peel. Many of these phytochemicals are undergoing research for their antiinflammatory and antioxidant properties against disease. One of these compounds is d-limonene found in the peel is getting tested for its neutralizing effect on gastric acid to relieve heartburn and gastro-esophageal reflux disease (GERD). The chemical also showed activity on cancer cells in studies. Research on oranges and their juice is underway to further verify their effects on allergies including asthma (vitamin A and C), inflammation (phyto-

chemicals), cholesterol and vascular disorders (pectin, B3, carotenoids), and cancer (soluble fiber, phytochemicals). Being affordable and widely available neither diminish the superfruitâ&#x20AC;&#x2122;s popularity nor its importance to health and disease. Fresh whole, dried, juiced, or cooked with its pith and rind, the orange is an important fruit to include in our daily diet with beverages, desserts, marmalade, in gravies, yogurt, snacks, salads and cakes. The high vitamin C content of fresh orange juice makes it a good base for fruit salads in order to stop other fruits like apples from oxidizing (turning brown) and also to maintain their fresh appearance. Whole fresh oranges and their freshlysqueezed juice with pulp are exceptionally delicious, quenching to thirst, and valuable to health. Donâ&#x20AC;&#x2122;t discard the peel and pith; they come with equally precious nutrients and phytochemicals. Individuals with medical conditions or on medication should consult their physicians when they decide to introduce anything new in their diet even if it is natural, MT

MAY-JUNE l 2010

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INDIA HEALTH CARE

EXPERT

VIEWS THIS IS the plaintive expression of a victim of the disease know as Arthritis. ARTHERITIS today drives millions of sufferers to their physicians each year seeking relief from the pain, immobility, and deformity it can cause. In India, according to records, ARTHERITS has reached an epidemic level as many as 100 million people, who comprise about 10% of the country’s population suffering form this crippling disease. Arthritis disorders of one kind or another have always plagued mankind and animals. Many people suffer form the aches and pains of damaged or inflamed joints. Some are just uncomfortable and some become crippled as result of the disease that has been recognised since prehistoric times but understood in only

“arthritis” is about as useful and specific as the word ‘infection’ and just as there are hundred different types of the infection, there are over a hundred different types of “arthritis”.

WHAT CAUSES ARTHRITIS :i.

Normal ageing process and wear and tear are the likely factors for causing lack of elasticity and the flexibility of the cartilage in the joints. ii. Overstraining the back may cause damage to the ligaments and other vertebral discs. iii. Occupation and lifestyle may also be related to Arthritis. For eg. A particular kind of posture on strain on a particular joints

ARTHRITIS Cause and treatment “Once the pain started in all my joints, my whole life was just pain.” the past few decades. Any part of your body can become inflamed or painful form arthritis. Arthritis refers to the painful inflammation of a joint. In some forms of Arthritis inflammation brings with it swelling, pain and redness. Some forms of the disease are the result of normal ware and tear on the body structure whereas other forms have no connection with these natural processes. There are some forms which are of constant and lasting nature whilst some such as bursitis, housemaid’s knee and tennis elbow may be of transient nature. The first thing to get out of the way is the myth that there is a such thing as a single disease called “Arthritis”. The truth is that the word

40 MAY-JUNE l 2010

may cause osteoarthritis of that part of the joints. iv. Excessive weight may also affect the larger weight bearing joints – chiefly hips, knees and spine. v. Hereditary factor – incidence of rheumatioid arthritis is higher than expected in twins and first degree relations. vi. Rise in uric acid in blood serum is likely to cause gout. vii. Mental tension/Stress cannot be ruled out for the emotional and physical mainifestation of the disease, pain and depression.

EXPERT

VIEWS viii. Damp and cold weather often causes and aggrevates this disease. ix. Having stiffness or pain when you move, could be sign of arthritis.

OTHER FACTORS THAT CAN CAUSE ARTHRITIS :A. B. C. D. E. F. G. H.

Hidden Birth Defects. Injuries Infections Drug side effects Biochemical factors Nutritional deficiencies Hormonal Factors Altered Immune System.

MAJOR FORMS OF ARTHRITIS Osteo Arthrits Rheumatoid Arthritis Osteo Arthritis :- Occurs most often at the ends of the fingers, thumbs, neck, lower back, knees and hips. It is the most common form of Arthritis. It is a degenerative joint disease, the degenerative factor being associated with the articular cartilage and joint surfaces. Patients know this disease as old age arthritis. All the joints in the body may be affected by Osteo arthritis. However it is most commonly experienced in the weight bearing joints, knees, hips and lumber spine. Physicians categorize cases of Osteoarthritis as primary and secondary. The primary form seems to begin by itself, with no specific cause, while the secondary type may have many causes but often result from too much stress and strain on a joint. Primary Osteo arthritis occurs mostly in women and may have hereditary component because it seems to appear more in some families than in others. Osteo arthritis can be diagnosed by X-Ray examination. Rheumatoid Arthritis: - It is the second most common form of arthritis. It is an inflammatory disease though involved with joints, it is not degenerative. It is an auto immune disease in which the body immune system (the body’s way of fighting infection) at-

tacks healthy joints, tissues and organs. The natural defence mechanism of the body recognizes some component of the joint lining (Synovium) as an enemy and attacks it. When an immunological attack is taking place it is normally accompanied by inflammatory reaction. Inflammation of the synovial membrane may spread to other parts of the joint and the inflamed tissue may grow into the cartilage surrounding the bone ends, causing it to deteriorate. When the cartilage disintegrates, scar tissue forms between the bone ends, fusing the joints, making it rigid and difficult to move.

TEST FOR DIAGNOSIS :i. ii.

iii.

X-ray ESR(Erythrocyte sedimentation rate) – indicates the presence of any inflammation in the body. RA factor ( Rheumatoid factor) – an abnormal antibody present in most people who have Rheumatiod, arthritis. In normal conditions the presence of an antibody is nil.

OTHER FORMS OF ARTHRITIS :A. B. C. D. E.

Anky losing spondylitis Bursitis Carpat Tunnel Syndrome Gout Polymyalgia rheumatica & systemic Lupus Erythematosus F. Infectious Arthritis G. Juvenile rheumatoid Arthritis H. Lumbago or Fibrostis I. Polymyositis J. Psoriatic arthritis K. Reactive arthritis L. Rheumatic Fever M. Tendintis N. Tennis elbow

TREATMENT OPTIONS FOR ARTHRITIS :● ● ● ● ● ● ●

Pain Relif Medications Corticosteroids NSAIDS Surgery Nutritional Suppliments Heat and cold treatments Massage, Rest & Exercise

Pain Relief Medication :- Drugs that relive pain are often used in the treatment of arthritis, Although they may provide some temporary relief, they do not actually help in arthritis. Pain killers such as acetaminophen, propoxyphene, oxycodone, Demerol and codeine are used in short term treatment of arthritis pain. Corticosteroids :- Steroids are the most potent anti-inflammatory drugs available. They can rapidly reduce pain and inflammation. But they must be used under a physican’s careful supervision because they can cause numerous side effects if taken in high daily doses from more than a 2 months periods. Over long periods of times, the bone becomes brittle, the skin becomes thin and cataracts may develop. Steroid users may also become psychologically dependent on them, making it difficult to stop inspite of their physicians advice.

SOME MEDICATION GENERALLY APPLIED ARE :● ● ●

Adalimumab, Humira /Inj Anakinra, Kineret (Injectable) Azathioprine – Injection, Imuran ● Cox-2 Inhibitors ● Infliximab – Injection, Remicade ● Ieflamomide, Arava ● Methotraxate – Injection, Rheumatrex ● Salfaslazine, Azulifidine ● Neproxen ● Methyprednisolove, Medrol, Depo-Medrol ● Diclofenac, Voltaren, Cataflam,Voveron-SR ● Surgery :- One of the major treatment aspects is surgery which include– ● Partial Joint Replacement ● Total Joint Replacement Conclusion : After briefing almost all the general aspects of this crippling disease – called Arthritis, one must say that one can control arthritis successfully in the early stage, otherwise it may prove disastrous. MT

MAY-JUNE l 2010

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EXPERT

ORTHOTICS & PROSTHETIC

VIEWS

THE RECIPROCATING Gait Orthosis or patients with spina bifida, traumatic paraplegia, muscular dystrophy, and RGO is the most frequently used brace for osteogenisis imperfecta. the ambulatory needs of a paralyzed child RGO offers the following advanor adult. There are other types of RGO’s tages: presently in use, the dual-cable and horizontal cable produced by Fillauer, Inc., l Efficient ambulation - compared to and others. RGO braces provide excellent other RGOs the ISOCENTRIC® is more walking function as compared to other energy efficient. This saves exertion devices. Hands-free standing and the use for people with muscle weakness. Also of the orthosis counteracts the tendency for patients prone to weight gain the for hip contractures. With every step, as ease of walking encourages more one leg flexes, the other leg must extend physical activities. The hip muscles MOHAMMAD TAHIR JAMAL and thereby stretch out the hip contract- Orthotics & Prosthetic DUBAI that are used for walking are exercised ing structures. Agile patients can be fitand conditioned as the person walks in ted as early as 18 months of age, giving the brace. them a better chance for walking and standing and l “Hands-free” standing, balance and support - Wearers therefore enjoying earlier the physiological, skeletal and can have their hands available for activities of function psychological benefits of being upright. while standing. The brace not only stabilizes the hip, knee and ankle joints but it also balances (positions) the perRGO BENEFITS son so they can stand without the use of crutches or RGO is a walking brace for people with little or no con- walkers. trol of their lower extremities often due to neuromuscu- l Dynamic “hip stretching” - Many Spina Bifida and peolar disorders or injuries. The device is ideally suited for ple with paraplegia are prone to hip flexion contractures.

THERE ARE other types of RGO’s presently in use, the dual-cable and horizontal cable produced by Fillauer, Inc., and others. RGO braces provide excellent walking function as compared to other devices. Hands-free standing and the use of the orthosis counteracts the tendency for hip contractures. With every step, as one leg flexes, the other leg must extend and thereby stretch out the hip contracting structures. Agile patients can be fitted as early as 18 months of age, giving them a better chance for walking and standing and therefore enjoying earlier the physiological, skeletal and psychological benefits of being upright.

RGO BENEFITS RGO is a walking brace for people with little or no control of their lower extremities often due to neuromuscular disorders or injuries. The device is ideally suited for patients with spina bifida, traumatic paraplegia, muscular dystrophy, and osteogenisis imperfecta.

RGO OFFERS THE FOLLOWING ADVANTAGES: Efficient ambulation - compared to other RGOs is more energy efficient. This saves exertion for people with muscle weakness. Also for patients prone to weight gain the ease of walking encour-

44 MAY-JUNE l 2010

EXPERT

VIEWS

This tendency is counteracted by the fact that the brace connects the two legs in such a way that flexing of one leg causes extension of the opposite side. It is like getting therapy or stretching with every step a person takes. l Steps are achieved by advancing the leg one of three ways. 1. Use of hip flexor muscles. 2. Use of lower abdominal muscles. 3. Use of trunk extension CARE AND MAINTENANCE OF RGO’S RGO components are made from high strength aluminum (2024-T4). It is possible to make minor adjustments or bends without annealing or softening of the aluminum. To make major adjustments or bends requires annealing or softening of the aluminum to prevent the aluminum from becoming brittle.

ages more physical activities. The hip muscles that are used for walking are exercised and conditioned as the person walks in the brace. “Hands-free” standing, balance and support Wearers can have their hands available for activities of function while standing. The brace not only stabilizes the hip, knee and ankle joints but it also balances (positions) the person so they can stand without the use of crutches or walkers. Dynamic “hip stretching” - Many Spina Bifida and people with paraplegia are prone to hip flexion contractures. This tendency is counteracted by the fact that the brace connects the two legs in such a way that flexing of one leg causes extension of the opposite side. It is like getting therapy or stretching with every step a person takes. Steps are achieved by advancing the leg one of three ways. 1. Use of hip flexor muscles. 2. Use of lower abdominal muscles. 3. Use of trunk extension

Take the following steps: 1. Remove all springs and screws from part to be annealed. 2. Hold the bar horizontally. 3. Apply some wet soap to the top surface of the area to be bent. 4. Heat the undersurface of the area with a torch until the soap starts to turn dark brown. 5. At the very moment the soap starts to turn dark, drop the part quickly into a container of cold water. 6. Try bending it now, it should feel soft and easy to bend. If it still feels hard repeat the annealing process. Repeat the process as many times as it takes to achieve the desired shape. As you continue bending the aluminum will work harden over time even as the patient continues to use it MT

CARE AND MAINTENANCE OF RGO’S RGO components are made from high strength aluminum (2024-T4). It is possible to make minor adjustments or bends without annealing or softening of the aluminum. To make major adjustments or bends requires annealing or softening of the aluminum to prevent the aluminum from becoming brittle. Take the following steps: 1. 2. 3. 4. 5.

Remove all springs and screws from part to be annealed. Hold the bar horizontally. Apply some wet soap to the top surface of the area to be bent. Heat the undersurface of the area with a torch until the soap starts to turn dark brown. At the very moment the soap starts to turn dark, drop the part quickly into a container of cold water. Try bending it now, it should feel soft and easy to bend. If it still feels hard repeat the annealing process. Repeat the process as many times as it takes to achieve the desired shape. As you continue bending the aluminum will work harden over time even as the patient continues to use it. MT

MAY-JUNE l 2010

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SPECIAL

FEATURE

Doctor

apperiance Survey of patients' preferences for doctors' appearance and mode of address ABSTRACT Objective To document patients' preferred dress styles of their doctors and modes of address. Design Descriptive survey. Setting Inpatients and outpatients at a tertiary level hospital, New Zealand. Participants 202 inpatients and 249 outpatients, mean age 55.9 (SD 19.3) years. Main outcome measures Ranking of patients' opinions of photographs showing doctors wearing different dress styles. A five point Likert scale was used to measure patient comfort with particular items of appearance. Results Patients preferred doctors to wear semiformal attire, but the addition of a smiling face was even better. The next most preferred styles were semiformal without a smile, followed by white coat, formal suit, jeans, and casual dress. Patients were more comfortable with conservative items of clothing, such as long sleeves, covered shoes, and dress trousers or skirts than with less conservative items such as facial piercing, short tops, and earrings on men. Many less conservative items such as jeans were still acceptable to most patients. Most patients preferred to be called by their first name, to be introduced to a doctor by full name and title, and to see the doctor's name badge worn at the breast pocket. Older patients had more conservative preferences. Conclusions Patients prefer doctors to wear semiformal dress and are most comfortable with conservative items; many less conservative items were, however, acceptable. A smile made a big difference.

INTRODUCTION First impressions can make a difference. How a doctor dresses may be important in determining the

48 MAY-JUNE l 2010

SPECIAL

FEATURE success of the patient-doctor relationship. Doctors' attire has been moulded by tradition and fashion over centuries. The past decades have seen major changes to the medical workforce and to societal expectations that have led to changes in doctors' choice of dress. One change is the increased proportion of female doctors entering the profession with no traditionally defined "dress code." Another is the move away from medical paternalism, resulting in fewer doctors choosing the traditional white coat. Overall, doctors' dress styles have become less formal than in previous decades. Most previous studies have focused on white coats. Two Australian studies showed that 36-59% of patients thought that junior doctors should wear white coats. Reasons given included professionalism, identification, and hygiene, yet white coats may be a source of, rather than a barrier to, cross infection. British and American studies carried out up to the late 1990s showed that patients were more comfortable with traditional styles of appearance, such as white coats, formal suits, short hair, shirts, and ties.5 6 Casual items such as sandals, sports shoes, and jeans evoked negative responses. Other factors, such as neatness or facial expression, were also considered important and had the potential to over-ride the effects of attire.7 8 Reported preferences may be contradicted when patients see actual examples of different dress styles.9 Two studies involved dress styles being alternated in doctors to compare measurement of patient satisfaction, and found that dress did not correlate with estimates of a clinician's courteousness, concern, or professionalism.9 10 Just as fashion changes so may opinions. More contemporary views are needed. Furthermore, few studies have looked at clothing options other than white coats. Preferences may be determined by the familiar,

so that if a doctor wears a white coat this may become acceptable to the patient. Similarly, style of dress may depend on the work culture of an institution. Many doctors adapt their styles to fit in with colleagues' expectations, whereas some attempt to stand out deliberately. Doctors may also dress in a way that they feel is acceptable to their patients, and it is likely that patients dress to please their doctors. These complex interplays can result in novice doctors becoming unclear about best practice, and many of our junior colleagues have asked for current information about what dress styles are acceptable to patients. We documented the preferences of a range of patients within one hospital, with the aim of informing doctors' practice.

were surveyed sequentially over another week. Inpatients were excluded if the nursing staff deemed them too unwell or if they were absent from their bed for an extended period on the specific day. Our survey comprised two parts. For the first part we presented patients with two sets of six photographsâ&#x20AC;&#x201D;one set of a young male doctor and the other of a young female doctor (see bmj.com). Each photograph depicted a different dress style. These styles were casual, jeans, semiformal, white coat, and formal suit. The sixth photograph showed a semiformal style with the doctor smiling. The casual photographs showed the male doctor wearing khaki trousers and a polo shirt and the female doctor wearing a sleeveless top, sandals, and short skirt. Other photographs showed both doctors wearing jeans, but with the male doctor wearing a short sleeved shirt with a collar and the female doctor a long sleeved knitted top. The semiformal photographs showed the male doctor wearing dark trousers with a long sleeved shirt and tie and the female doctor a blouse with a dark coloured skirt or trousers. The white coat photographs had both doctors wearing dark trousers. A fifth style had male and female doctors wearing

METHODS We invited adult inpatients and outpatients at Christchurch Hospital, New Zealand to take part in the study. Outpatients attending clinics that covered a range of medical and surgical specialties were approached consecutively in the waiting room over one week in December 2003. Inpatients from a wide range of wards

MAY-JUNE l 2010

SPECIAL

FEATURE dark suits. For all photographs the stance, position of the stethoscope, and hairstyle were kept constant. The photographs were presented to patients in random order.

DOCTORS' DRESS Patients were asked to rank each set in order from their most preferred doctor (ranked 1) to their least preferred (ranked 6). They were asked to choose their four most preferred doctors from the complete set of 12 photographs (no order or sex restriction required). In the second part of the survey the patients were asked to complete a written questionnaire, which included requests for personal information and questions on the degree of comfort each respondent felt with doctors wearing specified items of clothing. Responses were graded according to a five point Likert scale, ranging from "very uncomfortable" to "very comfortable." In addition participants were asked where identification tags should be worn, what name they liked to be referred to by their doctor (first name or title and surname), and how they liked doctors to introduce themselves. We provided four options for a doctor's introduction: first name only, first and last name, title and first and last name, and title and surname. Options for the location of an identification tag were at the waist, breast pocket, or anywhere as long as a name badge was worn. We calculated mean ranks for the photograph sets and compared these using Student's t tests. Mean scores were calculated for each Likert scale question. We used analysis of variance or Student's t test to compare respondent's ages according to preferences and to compare rankings or scores according to age groups. A Bonferroni correction was made to adjust for multiple comparisons such that differences were regarded as significant if the P value was less than 0.0012. We calculated a projected sample size of 450 to provide 0.80 power at = 0.05 to obtain descriptive statistics with a 4% margin of error.

50 MAY-JUNE l 2010

RESULTS The sample population comprised 606 patient; 155 declined or were unavailable. We recruited 249 outpatients and 202 inpatients, comprising 214 men and 232 women (five did not provide their sex) with a mean age of 55.9 years (SD 19.3 years). Six people did not provide their age. In total, 127 people were aged less than 45 (28%), 144 were 45-65 (32%), and 174 were more than 65 (39%). Figure 1 shows the distributions of mean ranks for each of the clothing styles, including the results for the photographs with doctors smiling. Patients ranked the semiformal style the best, especially when accompanied by a doctor smiling. Table 1 shows the mean rankings and significance of the differences for paired dress styles. Each style is compared with the next most popular style overall. Table 2 shows the proportions of each style chosen among patients' top four.

STYLE CHOSEN IN PATIENTS' TOP FOUR A patient's age was significantly associated with the photograph rankings for some clothing styles. The smiling photograph was excluded from this analysis. Older people gave more negative rankings for the male doctor in semiformal style (mean ranking 1.9 for people under 45, 1.9 for people aged 45-65, and 2.5 for people older than 65; P < 0.0001). We found no effect of patient's age for the female doctor in semiformal style. Older patients gave more positive rankings for male doctors wearing white coats (mean ranking 2.9 for people under 45, 2.5 for people aged 45-65, and 2.3

for people older than 65; P < 0.0001) and for female doctors (mean ranking of 3.2 for people under 45, 2.7 for people aged 45-65, and 2.4 for people aged more than 65; P < 0.0001). The relative rankings of the selected dress styles for female and male doctors, respectively. Age was significantly associated with responses to specific items of clothing. Items worn by female doctors that were significantly (P < 0.001) less acceptable to older patients were (in order starting with the least acceptable by mean ranking) facial piercings, short tops, brightly dyed hair, training shoes, sandals, loose hair, skirts above the knee, long earrings, several rings, and sleeveless tops. Items worn by male doctors that were significantly (P <

SPECIAL

FEATURE duce themselves by title and first and last name ("Dr Jane Smith"), 27% (122) by first and last name ("Jane Smith"), 15% (68) by title and surname ("Dr Smith"), and 10% (46) by first name only ("Jane"). We found no clear preference according to age (F = 1.33, df = 3, P = 0.27). Most patients (344, 76%) stated that doctors should always wear a name badge. The breast pocket was the preferred site (280, 62%), with "anywhere as long as they have a name badge" the second most popular (117, 26%). Only 9.5% (43) of patients thought that the waist was the best place for a name badge.

DISCUSSION

0.001) less acceptable to older patients were (starting with the least acceptable by mean ranking) facial piercings, brightly dyed hair, earrings, T shirts, training shoes, long hair, several rings, tie depicting a cartoon character, and no tie.

FEMALE & MALE DOCTORS' ITEMS Most patients (356, 79%) preferred to be called by their first name, with only 20% preferring title and surname. Participants who preferred to be called by their title and surname were older (mean age 61) than those who preferred to be called by their first name (mean age 54; t = 3.1, P < 0.01). Nearly half (208, 46%) of the patients preferred doctors to intro-

Patients prefer doctors to dress in a semiformal style, but when accompanied by a smiling face it is even better, suggesting a friendly manner may be more important than sartorial style. Although previous studies have shown that patients prefer doctors to wear white coats, we found that patients prefer a semiformal style of dress over formal suits and white coats. In line with previous studies, casual dress styles were less popular. This finding, and the association with age, suggests the beginnings of a trend away from patients preferring white coats. In general, patients prefer more conservative items of clothing. Most patients prefer their doctor to call them by their first name but prefer doctors to introduce themselves using title and first and last names. Few patients prefer the most casual option of first name only or the most formal option of title and

surname. The breast pocket was the most favoured location for a name badge. The size of our study provided a good cross section of opinions and gave sufficient power to detect small differences in patient preferences. The use of ranking of photographs provided good comparative data and overcame the problem where people may state preferences in theory that are different from preferences in practice.9 The use of the smiling option in relation only to semiformal dress may have introduced some bias. For example, the higher preferences for the semiformal non-smiling doctor may have arisen by its association with a smile on another photograph. Ideally each dress style would have been presented with a smiling and non-smiling version, or the smiling option should have been randomly associated with any of the dress styles. Although these results are representative of the patient population at one hospital in New Zealand, we cannot be sure they would be generalisable to other populations. In view of differences compared with earlier studies, repeating this study at regular intervals to track secular changes would be of value. We predict that the trend will continue for decreasing popularity of white coats. Although sex interactions were not apparent in this study, looking more specifically for this would be worthy of further study. Similarly, qualitative work that explores why patients react in certain ways would be of interest. Dress style and manner are well within a doctor's control and therefore can be altered to fit most with patient preference. In the New Zealand setting this would involve dressing in a tidy, semiformal manner in conservative clothing. Asking patients if they prefer to be called by their first name may aid comfort. Doctors should introduce themselves fully and clearly, supplemented by a name badge worn at

MAY-JUNE l 2010

LIFE

GUARD

Emergency

Oxygen Guideline With the publication of the emergency oxygen guidelines by British Thoracic Society (BTS),

52 MAY-JUNE l 2010

LIFE

GUARD BY DR.SHEREE SMITH, Imperial College London, UK

of ear probes are recommended.

MANY CLINICIANS may reflect on this new guidance and re-evaluate current emergency oxygen protocols within their own departments. Oxygen therapy is widely used in both chronic and acute conditions and trauma care. This evidence based guidance from the UK seeks to provide a clear oxygen management pathway for clinicians as well as make available detailed information on the subject area of the physiology and pathophysiology of oxygen. The primary change to practice within this guideline is the use of oxygen titration to achieve a Sp02 within a predetermined oxygen saturation target range as measured by pulse oximetry.

EMERGENCY GUIDELINES

RINCIPLE AIM The principle aim of oxygen therapy is to relieve hypoxaemia. Oxygen therapy should be used to achieve normal or near normal saturations (94% to 98%) in most patients, apart from those who suffer from particular conditions where their physiologic response may be different, such those at risk of hypercapnia respiratory failure. For patients with chronic diseases where hypercapnia is known, this guideline indicates that oxygen therapy ought to be delivered 24% at 2-4 litres in hospital settings to achieve a target oxygen saturation within a range of 88% to 92%. For patients who are critically ill and not hypercapnic, a high concentration of oxygen is often an imperative with The principle aim of oxygen therapy is to relieve hypoxaemia the documentation to the percent of concentration, flow rate and the patientâ&#x20AC;&#x2122;s oxygen saturation at commencement of therapy, being of equal importance. We now know that patients who experience breathlessness without a physiological basis such as hypoxaemia, benefit little from oxygen therapy and that the use of non-pharmacological interventions are worth considering. In acute situations, accurate clinical information is extremely important and in observing the effect of oxygen therapy the need for monitoring oxygen saturation through the use of pulse eximetry can not be underestimate. When using pulse oximetry, one needs to be aware that readings may be inaccurate when nail varnish or false nails have not been removed. Also hand tremors are known to comprise the accuracy to these situations the use

This BTS emergency oxygen guideline supports previous published information for both asthma and Chronic Obstructive Pulmonary Disease (COPD) guidance. Similar to those who experience trauma without any other underlying chronic condition, high concentration oxygen at high flow is recommended by the SIGN and BTS (2008) guideline for people who experience an acute asthma episode. In addition, it is suggested that oxygen therapy should be titrated to achieve saturations of at last 92% in asthama Oxygen therapy is widely used in both chronic and acute conditions and trauma care Patients. The emergency oxygen guideline goes further by advocating that any wet nebulisation should be delivered through an oxygen-driven device particularly when the acute asthma patient is

MAY-JUNE l 2010

LIFE

GUARD in a critical sate. At the beginning of this guideline there is an algorithm for the clinical management of adults with acute asthma in emergency departments and this quick summary may prove useful for clinicians in busy departments. For people with COPD a number of considerations are required when implementing oxygen therapy as we know COPD has different pathophysiology to asthma. People who experience frequent exacerbations have a more rapid decline in lung function and quality of life. The emergency oxygen guideline recommends that people who experience an exacerbatin of their COPD should be given oxygen therapy through a venturi mask at 28% or 24% at the appropriate flow rates according to the devices. The emergency oxygen guideline further and suggests that the patients clinical history may play a significant role in the setting of target oxygen saturations to be achieved. For example, a small proportion of COPD pa-

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tients have ongoing hypercapnic respiratiory failure (10%) whilst others with mild disease may continue to have normal blood gases which only deviate when they experience an exacerbation. Therefore it is clinically important to assess COPD patients on a case by case basis to be able to determine a target saturation range to be achieved through oxygen therapy titration. This emergency oxygen guideline has a lot to offer the clinical management of patients in the emergency department . The extensive physiology and pathophysiology sections add support for the appropriate use of oxygen as a therapy. Furthermore this additional information provides a substantial update for busy clinicians on the evidence available for the use of emergency oxygen. MT

54 MAY-JUNE l 2010

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