Thursday, August 27, 2009

BUERGER'S DISEASE




Tonite, one gentleman in his late twenties, came to our A&E Dept. with the above problem. He is suffering from this problem more than one year. He was previously treated in government hospital. On further questions, he claimed that he was a heavy chronic smoker and just quit recently. He came to A&E because he could not stand the pain on his fingers and toes. Some of his fingers and toes were already lost. At a glance, I diagnosed him as having Buerger's Disease. Detail about Buerger's Disease you can read here and also here.
When I asked him what is his occupation, he replied, "I was working at the Chemical Production Company. Now I already quit". I dont know whether his occupation has some relationship with his illness or not. I need to do some literature review on this subject. However, as far as my clinical knowledge on Buerger's Disease,I am sure it is related to heavy tobacco smoking. With this posting, I urge all of my fellow visitors of this blog who are smokers, please QUIT SMOKING. It is better now than later.

Personal Hygiene



Personal Hygiene is one of the preventive & control measures advocated and endorsed by WHO in fighting the spreading of infections including H1N1.
Personal hygiene which includes a practice of washing your hands frequently is one of the most practical and easiest control measures in occupational health. However, due to bad habit and 'syndrome of short cut' we always omit washing our hands particularly before eating. In many industries especially in food and healthcare industry, washing our hand is a good and compulsory practice for the benefit of our own health, patient and food's safety.
For devoted muslim, personal hygiene is a routine practice because at least 5 times per day they practice it via the act of taking 'wuduk' (ablution) before they perform the 5 prayers. In wuduk practice, not only you wash your hands but almost all part of your body : mouth, ear, face and feet. So let practice Personal Hygiene in our daily life. Prevention is better than Cure

Wednesday, August 26, 2009

No indication, No test


Yesterday, one gentleman came to our A&E during my duty time and requested from my nurse to do a test for H1N1. The nurse asked him, did he has fever, cough or flu (the common symptoms of H1N1 illness). He replied, "No". So my nurse told him that there is no need to do the test because there is no indication. He insisted to have a test and said he is willing to pay. At last, the nurse asked him to see me.
I explained to him that : 1. He has no indication for the test 2. The test which is available at our hospital is a rapid test, it takes about 30 minutes to get the result but its specificity and sensitivity is only around 80%. Meaning that it only can say you have infection caused by Influenza A or B or both BUT cannot confirm it is H1N1. If the test is positive for Influenza A, the chances to have H1N1 infections is high. BUT due to reason no 1, I turned down his request although he is willing to pay. The issue is not that he can afford to pay BUT there is no clinical indication. This is not a good clinical practice. During my medical student time, my Professor of Medicine always told us the purpose of doing investigations in clinical practice. The professor named it as 3C - To Confirm the diagnosis, To find the Cause and To monitor the Complications. So doing the test for this gentleman is not fulfilling the purpose of 3Cs as he has no symptom. And it is not cost effective also.

Sunday, August 23, 2009

BIOLOGICAL HAZARDS


BIOLOGICAL HAZARDS is one of the 5 categories of Health Hazards (The other 4 are: Chemical, Ergonomics, Physical & Psychosocial).
Biological hazard is any living organism that can cause harm to our health such as virus ( e.g. H1N1 which cause Influenza A H1N1 infections at the moment), bacteria (e.g. Mycobacterium tubercule which cause Tuberculosis) et cetera.
One thing we should remember of Biological hazards is it has no threshold exposure value or in another word it has no PEL value as for chemical hazards. At any value, biological hazards can cause disease, this especially true for H1N1 virus of which everybody does not have antibody. Generally to control the infection of biological hazards, we must break the infection chain.
We can divide infection by biological hazards into three types (depends on their mode of transmission) : 1. blood-borne infection (transmit through blood e.g. Hepatitis B which causes hepatitis), 2. oral-fecal infection (transmit via mouth & stool e.g. Salmonella which causes Typhoid) and 3. air-borne infection (transmitted via air e.g. TB which causes Tuberculosis).
For Influenza A H1N1 infection, it is caused by the droplet which contains the virus from the cough and sneeze of the infected person. The droplet can be transmitted via direct cough to the contact person through the air if another person stays within one meter distance. This social distance of one meter is including the 'breathing zone'. Besides that the person who cough out the virus can transmit it via his hand if he cough directly on his hand.
This is the reasons why the authority advise us to practise personal hygiene, respiratory hygiene or cough etiquette, stay more than one meter distance from the person who has cough or other symptoms of H1N1.
These control measures are the basic things we need to practice during this pandemic time. If you have the symptoms: practise personal hygiene - wash you hand with soap, if you have cough make sure you practise cough etiquette - when you cough or sneeze, cover your mouth or nose with a tissue paper then throw it into the dust bin and if possible dont attend any gathering or the crowd. However, if unavoidable, please use face mask. In another word, quarantine youself at home. Practicing this control measures is every one responsibility. At this point of time, we need to be VIGILANCE but do not PANIC.

Saturday, August 22, 2009

SELAMAT MENYAMBUT RAMADHAN AL-MUBARAK

Alhamdulillah, kita dilanjutkan usia untuk menemui kedatangan Ramadhan tahun ini dan akan mula berpuasa. Semuga ibadah puasa akan mentarbiyahkan diri kita untuk dapat mengawal hawa nafsu yang selalu mendorong kita bertindak sewenang-wenang. Semuga tarbiyah ini akan membentuk diri kita menjadi orang yang sobarin dan solehin. Semuga kedatangan Ramadhan ini juga akan meningkatkan kesihatan dan keselamatan kita serta persekitaran kita, Insyaallah.

Saturday, August 08, 2009

Compulsory Reading: Dr David Quek's posting on H1N1: 10 FAQs

I copied & pasted below, a very good information on H1N1 posted by Dr David Quek, President of Malaysian Medical Association. Please visit his blog at: myhealth-matters.blogspot.com

H1N1 Flu: What's Current, Some Dos & Don'ts...

Here are some Queries from the Press that I have collated and answered:

A(H1N1) Flu: Updates on 10 FAQs

by Dr David KL Quek
President MMA.

1) Can we distinguish between regular and H1N1 flu, without a lab test?

No, the flu is the flu, but there are variations in presentation. Some symptoms such as cough, runny nose, fever, body aches, fatigue, vomiting, diarrhoea occur more or less in every flu patient, but may present differently by different people. Some infected people have very mild symptoms, some in between, and a small minority, probably less than 10%, have severe features including the dangerous pneumonia.

However, from sentinel testing and surveillance by the Ministry of Health the last few weeks have shown that almost 95% of all flu-like illness are now caused by the H1N1 virus. Earlier some months ago, seasonal flu variants caused by the B and other A virus were the main causes, the bug causing most flu these few days is the A(H1N1). This appears to be the case also in neighbouring countries, meaning that the new virus is causing more havoc and symptomatic illness than previous types of flu (which are still in the community).

Because almost every flu-like illness (influenza-like illness or ILI) is due to H1N1, the MOH is now recommending that no testing to confirm this H1N1 will now be offered.

Treat as if this is H1N1 for ILI—symptom relief for mild symptoms (paracetamol, hydration, cough medicines, etc) and self-quarantine, social distancing, be alert for complications.

Most (~70%) do not need any anti-viral medications such as Tamiflu or Relenza. Only severe cases need to be referred to hospital for further treatment.



2) How should doctors decide if a person be given further specific treatment for H1N1?

If after 2-3 days, fever and cough symptoms do not improve, a recheck with the doctor is recommended, especially if there are features of difficulty breathing, severe weakness and giddiness, or, if the following risk factors are present:
  1. obesity (fatter patients seem to have poorer outcome and more complications)
  2. those with underlying diabetes, heart disease
  3. those with asthma, or chronic lung disease
  4. pregnant women
  5. those with reduced immunity, cancer patients, etc
  6. those with obvious pneumonia features

3) Many anxious people with flu-like symptoms want to be tested or treated for suspected H1N1, but are kept waiting or sent home, without being tested. Is this practice right?

There is no right or wrong practice as this outbreak is extensive and is stretching our resources to the limit. This is also the case not just here in Malaysia, but also elsewhere around the entire world!

The recommendation is now not to spend too much time and effort trying to get tested at designated hospitals or clinics—there is probably no need to do so. I have been informed that as many as 1000 patients queue anxiously at Sg Buloh hospital for testing, due to fear of the H1N1 flu.


So the message must be made clear: Most flu illness do not require confirmatory testing, and are mild and self-limiting. More than 90 percent will get better on their own, with symptomatic treatment—just watch out for possible complications, and risk factors as mentioned above.

Our resources are limited especially for testing. This is not just for Malaysia, but globally as well. The global demand for test kits and reagents for the H1N1 (PCR) is overextended and thus these tests are rationed due to this extreme demand.

Some 200 million test kits have been deployed worldwide, but this supply is critically short because of excessive demand, so most countries have to ration testing to confirm only the worst cases, so as to monitor the pandemic better.



4) Are doctors confused as to what to do in this outbreak, especially when they do not have ready access to confirmatory lab tests?

Not really. Earlier on there was some confusion as to what to do next and who to test or who to refer for further testing and admission. Now the rules are clearer.

There is no need to do any testing to confirm the H1N1 virus for any ILI—just assume that this is the case in the majority of cases. Treat symptomatically when symptoms are mild, reassure the patients and ensure that these infected patients practice good personal hygiene, impose self-quarantine and social distancing, wear masks if their coughing or sneezing become troublesome, and keep a watchful eye on whether the infection is getting better or worse.

If there is difficulty breathing and gross weakness, then patients should quickly present themselves for admission. Understandably this phase of worsening is not always clear or easily understood by everyone... But there is not much more that we can do—otherwise we will be admitting too many patients and this will totally overwhelm our health services.

But prudent caution would help to determine which seriously ill patients need more attention and more intensive care. Unfortunately however, there will be that odd patient who will progress unusually quickly and collapse even before anything can be planned—hopefully these will be few and far between.


A more important note, is that all doctors and nursing personnel should be very aware that they too have to take precautions, and employ barrier contact practices, if there are patients with cough and cold during this period of H1N1 outbreak, which is expected to last a year or two. Carelessness can result in the physician or nurse or nurse-aide becoming infected!


5) Are there sufficient guidelines from the Ministry of Health to address this situation?

I think there are sufficient guidelines from the MOH. Although some politicians have blamed the MOH and the Minister for being inept at handling this pandemic—in truth this is not the case.

It is useful to remember that this is an entirely new or novel virus, which no one previously had encountered before—thus its infectivity and contagiousness is quite high and almost no one is immune to this virus.

Perhaps, there will come a time when all the resources from both public and private sectors can be put to more efficient use. Some logistic problems will invariably occur, because human beings differ in their capacity to understand or follow directives, whatever the source or authority.

Also patient demands have been extraordinarily high and at times very difficult to meet—every patient necessarily feels that his flu is potentially the worst possible type and therefore requires the most stringent measures and testing...

Doctors are also unsure as to the seriousness or severity of this new ailment—and we are only now beginning to understand this better—so our less than reassuring style when encountering this new H1N1 flu is sometimes detected by an equally anxious patient and/or their relatives.

But there is only so much that we can do under such a pressure cooker of an outbreak which is spreading like wildfire!
But nevertheless we should not panic, and remember that most >90% of infected people will recover with very little after effects. Possibly only one in ten patients develop more serious problems which necessitate hospitalisation.


6) Is limiting H1N1 testing only to those who have been admitted to hospital justifiable?

I have explained the worldwide shortage of such testing kits and reagents. Also it is near impossible to test everyone, the world over. Besides, knowing now that almost all the flu-like illness in the country is due to H1N1 makes it a moot point to want to test for this, especially when most are mild.

The rationale for testing only those who need hospitalisation is to ensure that we are dealing with the true virus, and also help to isolate possible changes or mutations to this viral strain. The MOH is also constantly doing sentinel surveillance (random spot-testing at various sites around the country to determine more accurately the various virus types and spread that are causing ILI)



7) Are we short of anti-virul drugs (Tamiflu, Relenza)? Should I take Tamiflu?

These antiviral drugs were available to most doctors during the earlier scare of the bird flu virus, but now are severely restricted, although some orders are still entertained from individual doctors, clinics or hospitals. Remember that these have been block-booked by more than 167 countries who have been shown to have been penetrated by the H1N1 flu bug.

Our MOH has actually stockpiled some 2 million doses of the Tamiflu or its generic form. In the last inter-ministerial Pandemic Influenza task force meeting, this stockpile will be bumped up to 5.5 million doses to cover some possible 20% of the population.

Right now there is no shortage in the country. It is just that it is not readily available on demand for anyone just yet. The MOH is still of the opinion that this antiviral drug be used prudently and would like to register every patient given this drug.

The private sector on the other hand would like to have a looser control over the use of this drug—but we acknowledge that we should be meticulously prudent in its use. There is a genuine fear that resistant strains to this drug may develop with indiscriminate and unnecessary use—then we will all be in trouble with a drug-resistant H1N1 virus run amok!

Drug-resistant strains have been detected in Mexico, border-towns in USA, Vietnam, UK, Australia even. So we have to be vigilant and closely monitor the situation. Right now, the very limited usage of Tamiflu gives us good reason to be optimistic.

However, because of some unusual patterns of seemingly well people dying or having very critical infections, some people and doctors are wondering if these new strains have already reached our shores...
or have we been too late in instituting proper treatment...?

The rising number of deaths to 14 now, is quite worrisome, but our health authorities are watching this development very closely and are also checking the virus strain to see if this has mutated. We can only hope that this is not the case, for now.


8) What are some of the problems faced by doctors in dealing with the H1N1 problem?

It would be good if every medical practitioner keeps a close tab on the H1N1 pandemic, and remain fully aware of the developments and changes, which are evolving daily. Every doctor has to be learning on the trot, so to speak, to keep up with the progress of this outbreak and its management, so that we can serve our patients better.

Logging-in to the internet regularly, for more updated information will certainly help, instead of lamenting that not enough is being disseminated via the media thus far... Every doctor has to be more proactive and practice more responsible and cautious medicine during this trying period which is expected to run into at least 1 to 2 years. Importantly look out for lung complications, and the above stated higher risk profiles, and refer these patients quickly for further care.

Easier access to antiviral drugs and their responsible use and monitoring would help allay public fears of delay in treatment, but this should be tempered with care and not over-exuberance to dish out to one and all, the precious antiviral drug,
just for prevention—this may be a very bad move which can inadvertently create a worse outcome of drug-resistant bugs.

However, in the light of the very quick deterioration of some young patients who have died, it might be prudent to use antiviral treatment earlier and more aggressively.

We look forward to the specific H1N1 vaccine, when it does come our way, probably towards the end of the year. In the meantime, encouraging those in the front-line, heart or lung patients and frequent travellers to have the seasonal flu vaccination is a useful adjunct to help stem the usual problems from other flu types.



9) Are we doing everything that should or needs to be done?

Yes, if you check what other nations are doing, we are doing relatively well. We are not overstating the dangers and we have been quite transparent on the possibilities of this pandemic. Earlier, many agencies and even the public and doctors have accused us of exaggerating the pandemic, and our response was dismissed as being too much, even over the top! Unfortunately, it was only when some deaths occur that many are now decrying that we have done too little!

Also if you are quite honest about it, just compare with the countries globally, and you will notice that no one health or government authority has got this right, spot on.

We are all learning about this novel flu pandemic, and each country's response is coloured by its past experiences. In Hong Kong, China, Vietnam, Singapore and Malaysia we have had the SARS outbreak, so we are necessarily more paranoid! Also here the experience is that flu does not usually cause death in our community, unlike the west where seasonal flu kills some hundreds of thousands every year!

So the fear factor for this H1N1 flu is not nearly as great in the west, although it is slowly sinking in that its contagiousness and infectivity is far greater, and fears of its reassortment to a more virulent mutant form is growing, into the so-called second and/or third wave of this pandemic, but we will not know until a year or so down the line.



10) Is the public in general doing enough to help in controlling the outbreak?

I think the public is now reasonably well-informed as to this H1N1 pandemic. Perhaps, they are too well-informed, that they have a fearful approach to this virus. But the proper thing is not too over-react and to panic, although I know this does sound easier said than done.

It is almost a certainty that this flu will spread within the community—in schools, universities, academies, factories, work places, offices, etc. WHO has projected that possibly some 20 to 30% of the population worldwide will become infected by this novel flu bug, after studying various models of spread of past infections—the huge and very rapid spread worldwide is mainly due to air-travel. While older flu pandemics took 6 months to extend to so many countries, this H1N1 flu did so in less than 6 weeks!

In the worst case scenarios of course, this outbreak will be alarming—hospitalisations may be required for 100,000 up to 500,000 Malaysians, with perhaps as many as 5000 to 27000 infected patients (depending on the case fatality rate or either 0.1 to 0.5%) succumbing to this illness.

But because we have been monitoring closely and containing the outbreak thus far, with heightened awareness and greater social responsibility, it is possible to ameliorate the infectivity, spread and fatality that will unfortunately accompany this pandemic... Just how successful we will be in limiting these adverse outcomes remains to be seen, but we can be hopeful.

How can the public help? First learn and acquire good personal hygiene. If sick, please be responsible and stay at home, even in your own room where possible, wear a face mask (a cheap 3-ply surgical mask will do, because large droplet spread is the main danger). Do not go out, practice what is now known as social distancing (about 3 metres from anyone), and be socially responsible, don't go to public places and infect others—for young people this would be hard, but absolutely necessary—the spread is most rampant in this age group between 16 to 25 years.

When the illness does not go away after a few days or when you are deteriorating, get to the nearest hospital. Most importantly, be very aware and responsible!

Finally, keep abreast of all new developments, because these are evolving all the time. With keen awareness, prudent care, early detection and social responsibility, correct and prompt use of antiviral and other support medical care, and later mass specific vaccination, we can overcome this novel H1N1 flu! But it will take time, patience, public cooperation, much concerted effort and consume great resources.

Monday, August 03, 2009

7th Malaysia H1N1 victim is First Sarawak Victim

The death toll of H1N1 infection in Malaysia was increased to 7 where 24 year old pregnant lady became its 7th victim, who was admitted in ICU of Miri Hospital. Detail news, please click here.