|
Magazine
Operation needed?
|
Our panel of doctors offers advice and guidance on issues concerning mental health.
|
Name withheld:
I am 65 years. I have phimosis and was advised circumcision. Is there any non-drug therapy or is surgery a must? Ultrasound of the abdomen revealed a large simple left renal cortical cyst. What treatment is required? I do not have sugar or B.P.
Dr. S. Duraisamy, Consultant Urologist, replies:
Regarding phimosis, it is better to have a circumcision as early as possible. It is a fairly simple procedure, which can be done under local anaesthesia. There is no drug to replace surgery for phimosis especially at your age. Regarding a large left renal cyst, most are benign especially when there are no symptoms. But considering your age and size of the cyst, a CT scan of the kidneys could be done and, if necessary, a ultrasound guided aspiration of the cyst done and the fluid analysed for further treatment.
* * *
Dr. L.K. Joseph, Chennai:
My son, 3½, has phimosis. Is circumcision to be done? What is the average healing period?
Dr. S. Duraisamy replies:
Your son will need a circumcision operation, which has to be done under general anaesthesia because of his age. Circumcision can be done anytime after one year and the usual healing time is three to four days.
* * *
Paediatric help
Name withheld.
My daughter, now around two years, was treated for meningitis at five months. Around seven months, the doctors placed a sub-dural peritoneal shunt on the left side to drain the excessive CSF. She has had the shunt since February 2001 and is a normal child except for the shunt. Can it be removed now? If she needs to have the shunt for life, what is the effect on her development?
Dr. Prema Shankar,
Paediatrician, replies:
A sub-dural peritoneal shunt can usually be removed but it is left to the discretion of the neurosurgeon. Whether she is dependent on the shunt tube or not can be gauged only when it is removed. If features of raised intra-cranial pressure develop, then it will have to be reintroduced. A repeat CT scan would be necessary to decide the further course of action. A tube in situ will not hamper the development of the child, but she will have to have periodic checkups with the neurosurgeon to assess its proper functioning.
* * *
P. Subramanian, Vishakapatnam:
My wife (my maternal uncle's daughter) conceived in October 2001. Periodic check ups showed normal development of the foetus and the expected date was given as July 6, 2002. The boy, born the next day by caesarean, weighed 3.2 kg at birth and 3.42 kg after 60 days. He was found to have Dextracardia. Further lab reports revealed that the baby had Dextracardia with sytus inversus totallis. The doctor said that the child had two holes in the heart. The baby developed symptoms of jaundice and the blood reports and the scan reports have indicated that the problem is due to Biliary Atresia. The doctor has suggested surgery but is not sure whether the baby would withstand surgery. Besides surgery may not be effective and side-effects and further complications may arise in the liver after two to three years. He further indicated that the surgery is expensive and has to be carried out at the All India Institute of Medical Sciences (AIIMS), New Delhi, or at the Post Graduate Institute (PGI), Chandigarh. Is this surgery absolutely necessary? If surgery is not performed then will the child be affected? Can the surgery be performed anywhere in South India? Will the surgery be a one-time affair or will there be consequent/follow up surgeries?
Dr. Prema Shankar replies:
Your baby's history is very complex. Looking at all the problems, Biliary Atresia is a major and a life-threatening one. If the diagnosis is confirmed, then surgery is a must and is best done before eight weeks of life. The success rate is good, but is fraught with risks and there is the development of further complications, which can arise even after two to three years. The surgery is expensive and in Chennai, the Goverment Children's Hospital and the CHILDS Trust Hospital are two options, apart from the ones you have already mentioned. At the former it would be free, whereas at any private hospital, the cost would naturally be more, roughly Rs. 30,000 to Rs. 35,000. Since there may be many complications after the initial surgery, follow-up surgeries may also become necessary. Taking all these factors into consideration, a liver transplant is perhaps the answer, but it is very expensive (Rs. 25,00,000 to Rs. 30,00,000) and done only at the Apollo Indra Prastha Hospitals, New Delhi.
Coming to the heart problem, Dextracardia per se does not need any treatment, but you have mentioned two holes, though you have not stated what the defects are. So the heart will have to be assessed depending on the condition of the baby, and a discussion with the cardiologist, becomes a must regarding the risks involved.
The baby was delivered by caesarian section — you have not mentioned why.
The baby was 3.2 kg at birth and 3.42 kg after 60 days, (expected weight would be 4.7 kg).The inadequacy of weight gain is also a cause for alarm, in itself.
Considering all the problems, later, there has to a discussion with your wife and other family members, so that you can come to a decision, regarding the future of the baby.
* * *
Sugar trouble
A.V. Srinivasan:
What is meant by hb1a as applicable to diabetic patients and how is it determined? What are the safe limits of fasting and pp sugar levels? How does one avoid diabetic retinopathy, neuropathy and nephropathy? How do these apply to persons in the age group of 60 to 65?
Dr. Usha Sriram, Endocrinologist and General Physician, replies:
HbA1C or glycosylated haemoglobin is a stable minor haemoglobin component formed slowly and non-enzymatically from Hb and glucose. The rate of formation of HbA1C is directly proportional to ambient glucose concentration and also reflects blood sugar over a two to three month period. This is a supplement to periodic fasting, pre-meal and post-meal sugar testing. HbA1C is a simple blood test and is very valuable in the management of a diabetic. The American Diabetes Association recommends that HbA1C values should be maintained less than seven, which reflects a mean glucose value of 170 mgm per cent.
The rates of fasting and pp sugar depend on the age, presence of heart/kidney disease, pregnancy, visual impairment and the ability of the patient to deal with low and high sugar levels. Patients below 50 should have fasting sugar less than 120 and two-hour pp less than 150 and HbA1C at less than seven, closely mimic non-diabetic normal and will help delay or prevent complications.
Pregnant women need to maintain fasting values at less than 90 and two-hour pp values at less than 120 to prevent complications. For all others, pre-meal values between 140 and 160 are recommended. In those above 75 or persons with complications of diabetes but prone to low sugar, the pre-meal values are relaxed to 120-150 and post-meal values to 160-180. These are only guidelines and physicians will individualise the range based on other factors.
Problems, like diabetic retinopathy, neuropathy etc., are called micro-vascular complications. Retinopathy involves the retina and could be mildly or moderately severe and amenable to treatment or very severe with compromise of vision. Baseline eye exam with a formal fundus examination, yearly follow up, fundus fluoroscerin angiography when indicated and photocoagulation as advised by the ophthalmologist are necessary.
Neuropathy is involvement of nerve fibres that causes pain, numbness, burning or lack of sensation and foot ulcers. Treatment involves tight glucose control, having frequent foot examination, using proper footwear, avoiding walking bare feet, clipping nails, early attention to small ulcers and skin discolouration.
Diabetes is a leading cause of kidney failure. Blood pressure control with use of special medication like angiotensin converting enzyme or ACE, inhibitors and angiotensin receptor blocker or ARB help prevent nephropathy. Tight glucose control, protein intake in moderation, frequent surveillance for protein in the urine (especially micoralbuminurea) and kidney function (six to 12 months) are the other crucial steps in curtailing this complication.
(As the questions on diabetes are too numerous to be answered individually, the issue of management of the problem will be covered in an article shortly.)
* * *
Angry young man
Name withheld:
I am prone to anger. I simply sit around doing nothing if I get irritated and don't express the same. This is affecting my performance at work and relationships. I sometimes become suicidal. I am an epileptic. Is there any relation between my character and this problem?
Dr. Seshadri Harihar,
Consultant Psychiatrist, replies:
Earlier, we spoke of an "epileptic personality". But, there is no evidence that features like "anger" are more common among epileptics. In fact only a small proportion of patients with epilepsy suffer from major personality disturbances, and these do not conform to any distinctive pattern for epilepsy. It is important that an epileptic does not experience severe bouts of anger, as this can precipitate an epileptic attack. As your anger and irritability are affecting your performance at work and your relationships, you need to talk about it and not keep it to yourself. You say that you "sometimes become suicidal" — you definitely need a proper psychiatric evaluation. You require supportive psychotherapy and could require antidepressants for your suicidal feelings. Please consult a psychiatrist.
* * *
Name withheld:
My wife, 42, is well-qualified. She worked as a lecturer for few years but could not continue as there was no one to look after the house and our only daughter. We lost our second daughter at birth 12 years ago and my wife had not even seen the baby. Later she had a few abortions. I used to travel frequently, which meant an absence of four to five weeks at a stretch.
She is not interested in normal activities, has difficulty in concentrating and is not keen on religious activities. Now that my daughter goes to college, my wife stays alone in a large flat like a prisoner. For a year, she has been saying that everyone in the vicinity abuses her family and reacts like this at functions or outings. In short, from her point of view, everybody is jealous of and talks ill of her family. Even when my parents or friends telephone my daughter or me she says this.
Recently she wanted the phone disconnected as someone commented on her frequent calls to her parents. She also stopped the maid from work because of this issue. Her brothers are settled abroad and her parents are also likely to stay there. But my wife is not able to enjoy life at all. She avoids outings. Whenever she talks to her parents or brothers, she is all right. She is able to do household work as usual.
The problem is interaction with outsiders. I am really worried. She does not want to go to any doctor as she feels everything is fine.
Dr. Seshadri Harihar replies
Your detailed account of your wife's beliefs and experiences indicate that she has auditory hallucinations and delusional beliefs. Such people lack what we call "insight", the ability to realise that these phenomena are abnormal and are caused by a disturbance of mental functioning. So, she believes that her abnormal beliefs and experiences are real and that there is nothing wrong with her. In such a case, naturally she sees no reason to see a doctor.
From your description it is quite obvious that your wife is suffering from a psychotic illness and requires treatment. As she is unwilling to see a doctor, I suggest that you meet a psychiatrist without her and explain the situation and he will guide you as to how she can be helped.
* * *
G. Kumara Guru, Chennai:
My son, 23, is mildly retarded with hyperactivity and attention deficiency. Till he was12, he was in a special residential school at Tiruchi. We had to take him home because he became very depressed. We are unable to manage his problems or rehabilitate him. He is losing all the skills he learnt in the special school. He is now on Largactic 50 mg twice a day and Mazetol 200 mg at night. He also takes Respidon 1 mg and Fluwat 10 mg. Please advise on clinical management, training and rehabilitation.
Dr. Seshadri Harihar replies:
Your son needs a thorough assessment to determine his skills, his present level of functioning and mental state. This will tell us about the adjustment that his medication might require and the kind of training he needs. Only then can rehabilitation be planned. Unfortunately, there are few special centres for assessment, training and rehabilitation.
I would suggest "Vidya Sagar" (formerly the Spastics Society of India) — at No. 9 Ranjit Road, Kotturpuram, Chennai, (Ph: 24235478) — as a starting point. They will be able to give you specific guidance regarding his training and rehabilitation after he has undergone assessment.
* * *
Dear readers,
Please continue
to write in at:
`Ask the Doc', The Hindu, Sunday Magazine, Kasturi Buildings, 859 - 860 Anna Salai, Chennai 600 002
or
e-mail us at
magazine@thehindu.co.in
While every attempt is made to answer your questions, please keep your queries short and focussed and not send us your medical records and reports.
Printer friendly
page
Send this article to Friends by
E-Mail
Magazine
|
