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Thread: Medical Q & A... 6

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    Default Medical Q & A... 6

    Is it possible to avoid kidney transplant?


    Q. My husbandís age is 50 years and has a GFR of 30 and creatinine level of 1.4 mg/dL. He is suffering from high BP, which is under control in the range of 130/90 through regular medication. Otherwise he is active and alert. Is it possible that if he maintains the BP levels and his low-protein regimented diet, he may never require kidney transplant? Or will he require kidney transplant? If so how soon?

    A. Assuming the baseline serum creatinine of 1.4 mg/dL, the estimated Glomerular Filtration Rate (GFR) of your husbandís kidneys is approximately 50-55%. This means that he has over 50% of normal kidney function at his age, reflecting significant functioning of his kidneys. It is possible to delay the progression and many times halt the disease process if the risk factors for the kidney disease are kept in check. This includes strict blood pressure control (goal BP <130/80 mmHg) and avoidance of kidney toxic medications including continuous intake of common pain medications like Brufen, Nimulid and Voveran. In addition, he would need to undergo urine analysis test for any significant albumin (protein) leakage. Increased protein in urine is a marker of kidney damage and would make it necessary to be treated with particular class of blood pressure medications like Angiotensin Converting Enzyme inhibitors (ACE) or Angiotensin Receptor blockers. Kidney transplant or dialysis intervention is offered at the stage of kidney failure (end stage kidney disease) when one is left with less than 10% of normal kidney function at her or his age. It is certainly premature to worry about the end stage in your husbandís case while focusing on preventive measures.

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    Do I have ankylosing spondylitis?


    Q. I am 30 years old male employed in software industry. Since last three years I am having neck pain but now I started to have low back pain also. I underwent a lot of tests. Initially, the doctor told me that I am suffering from cervical spondylitis but he now thinks that it is ankylosing spondylitis. Could you please tell me what exactly am I suffering from?

    A. Diagnosis of ankylosing spondylitis is made on clinical grounds in patients who have the following clinical symptoms:

    1. Prolonged early morning stiffness in the spine (mainly lower spine) that may take up to one hour (or even more) for maximum possible improvement.

    2. Alternating buttock pains.

    3. Physical activity (including exercise) improves the symptoms but inactivity (taking rest) does not.

    4. Nights are more painful than the day time; moreover, the second half of the night gets disturbed due to increase in back pain that comes even on turning in bed.

    Young people who have these symptoms (at least 2 of the 4 or more) should get a test of their genes looking for a gene called HLA B27. The catch is that there are a large number of commercial laboratories, which claim to have the facility to do this test. Unfortunately, they use a technique called ‘Flowcytometry’ for performing this test. It gives wrong results. Therefore, one must find out a laboratory that used DNA-based technique using a method called ‘Nested-PCR’. X-ray of sacroiliac joints is also very useful, but only in late stages. In early stages (less than 2 years duration), MRI of sacroiliac joint with ‘STIR’ method looking for subchondral bone oedema, is another very useful confirmatory test for sacroiliitis, a hallmark of ankylosing spondylitis.

    The main problem is that there are very few rheumatologists (specialists in joint diseases) in the country. Most doctors, including Orthopaedic surgeons, internists have little idea of how to make the diagnosis of ankylosing spondylitis. Therefore, I strongly recommend that take a printout of this message and find out a rheumatologist for consultation as soon as possible without wasting any more time. The earlier you are diagnosed the better it would be for long-term outcome of the disease.

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    How to treat spring catarrh?


    Q. I have been suffering from spring catarrh since last 17 years. I have been using eye drops like optihist and also take triz tablets. I also used steroid eye drops like pyrimon when the redness worsens but then I suffer from glaucoma on prolonged use. Is there any treatment for the allergy because it’s affecting my personal and professional life due to the redness in the eyes? Can you suggest some medicines?

    A. Spring Catarrh is a chronic allergy that may not be completely ‘cured’ by treatment. It tends to have a seasonal occurrence, and reactivates twice a year during the season change: viz. February-April and September-November. Medication in the form of anti-allergic, lubricants and decongestants tend to control the flare up. Ketotifen drops used twice a day over long periods can be useful

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    Are the syringes sold in the market safe?


    Q. It is seen in places like Kolkata, Nursing Homes and other labs send people to our homes to collect blood samples. I would like to ask how can I ascertain that the syringes used is free from HIV/AIDS even if it is a sealed one. What procedure should we follow to make syringes 100% safe, if at all it contains HIV/AIDS virus?

    A. While it is correct that there have been reports of syringes being recycled fraudulently, if care is taken to purchase sealed disposable syringes from a reputable chemist it should be very safe. I do not recommend consumers sterilising syringes at home, the risk of infection and damage to the plastic material of syringes is significant. Ask your doctor/lab to use self-destruct syringes. They are available in India and cannot be re-used. If you like you can purchase them yourself and insist that they are used.

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    Will different blood groups cause problems in future?


    Q. I am 30 years old. I am AB positive and my fiancee is B negative. Will there be any complications in the future when we plan a baby?

    A. The Rh (rhesus) factor is a protein (antigen) present on the surface of red blood cells (RBCs). As it was first discovered in the rhesus monkey, it has been so named. Individuals carrying this antigen are called Rh-positive (Rh+) while those lacking it are Rh-negative blood group type (Rh-).

    Rh incompatibility (or Rh disease) is a state in which a woman with Rh-negative blood group is exposed to Rh-positive RBCs leading to the formation of antibodies against this protein (called Rh antibodies). Once these antibodies are made in the mother, they can cross the placenta into the developing baby’s circulation and destroy the baby’s RBCs which are Rh-positive.

    This can occur when an Rh-negative woman is carrying an Rh-positive baby or if an Rh-negative woman receives blood transfusion containing Rh-positive cells. In either case, her immune system is exposed to the Rh antigen (which is ‘foreign’ to her body) and begins producing Rh antibodies. During pregnancy and delivery, red cells from the baby enter the mother’s circulation. If the exposure is significant, the mother gets sensitised and begins to produce antibodies. When these antibodies cross the placenta and enter the baby’s circulation, they encounter Rh-positive cells, which are then destroyed by these antibodies leading to anaemia and jaundice in the baby. Delivery is the usual time when sensitisation occurs, and thus first-born babies are usually unaffected, as antibodies have not yet formed in the mother.

    A subsequent pregnancy with an Rh-positive baby can give rise to anaemia in the baby as these antibodies destroy the baby’s RBCs. Each successive pregnancy poses a greater risk to the baby. It is postulated that even less than 1 ml of Rh-positive blood can induce antibody formation while several studies have shown that ~30% Rh-negative individuals never form antibodies despite exposure to Rh antigen.

    The problem of Rh incompatibility is of clinical importance only in a pregnant woman or if blood transfusion is required. These circulating antibodies in a woman’s blood are otherwise harmless. Most institutions give human anti-D immune globulin (Rh IgG) antenatally to Rh-negative pregnant women. If a woman has been already sensitised, she needs to get the antibody titres estimated and be closely monitored during pregnancy. Babies born to such mothers too may require specialised neonatal care.

    The diagnostic evaluation includes maternal prenatal ABO and Rh typing, and an antibody screen. Depending on the results of the antibody screen, maternal antibody titres, and paternal and/or fetal RBC phenotyping are performed. If fetal RBC express the antigen against which maternal alloimmunisation has occurred, the pregnancy is then followed by measuring serial maternal antibody titres and abdominal sonograms.

    Pregnant mothers should have regular indirect antiglobulin tests. As a guide, anti-D antibody levels < 0.2 mg/ml require no action while higher levels require action; levels > 2.0 mg/ml typically are associated with severe disease. Prevention is now carried out with anti-D Ig (intramuscular within 72 hours of delivery) in all Rh-negative mothers giving birth to an Rh-positive child.

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    How should I deal with my domineering dad?


    Q. I am a 22-year-old female. I live in a very conservative family and my dad has a very negative attitude towards life. He is not willing to trust me and my younger brother for anything. Mostly he lives in some kind of doubt and is not willing to accept us as we are. He always scolds us and then he feels guilty about it so he buys us things and takes out for dinner. At times we are also at fault as me and my younger brother also lie to him and we have not had a very pleasant childhood. I have a very loving and caring mother and she also suffers emotionally because of my father's negative attitude. My dad is very outgoing and likes to mingle with people. He has got very good friends and is very cordial and social towards them. But he worries too much about things and wants everything to be according to his wish. Now I have started suffering more on my emotional and career front as he does not want me to go out of the house. If I do go out after taking his permission, he questions me all the time and worries a lot, which makes me feel guilty and angry. How should I deal with this situation?

    A. I understand it is a big predicament on your part as to understand how you need to deal with your dad. Your dad has had a set way of doing things all this while and it is perhaps now that you have started understanding the sense of control he wishes to have. In fact speaking lies or rebelling against his wishes would and could make matters worse, and in turn could affect his own feelings too. Although it is easier said than done, but the best approach would be to have a frank chat with him and negotiate the boundaries of what his expectations are and what your expectations or needs are. It might be a slow and difficult process but can be a sure shot, if done persistently with patience, love, affection and respect. Also, at some stage family counselling can be considered.

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    Are my kidneys damaged?


    Q. I am 37 years old. I was diagnosed with high BP (150/100) and subjected to tests. My cholesterol (250) and triglycerides (225) were found to be high. My albumin showed to be 80 mg/l. The doctor said that my kidneys are badly damaged. After taking medicines, my BP is now 130/80 and cholesterol is under control. I underwent two albumin tests, and the results showed it to be 8.5 mg/l on the first occasion and 3.70 mg/l on the second occasion. My urine routine test shows nil for all, except bile: absent/ pH 7.0, specific gravity: 1.005 and pus cells: 0-2 / hpf. My blood creatinine is 0.9 and urea is 21. I also got my urine (24 hours) tested, which showed microprotein 155.40 mg/l. Based on the above reports, I want to know if my kidneys are really damaged. What are the precautions I need to take?

    A. Persistent presence of albumin (a type of protein) amounting to >30 mg in urine collected over 24 hours is an early marker of kidney disease. Review of your repeat urine studies quantifying albumin does not show significant albumin leakage in the urine, while you seem to have normal kidney function (based on normal serum creatinine value). Hence, you do not have an evidence of kidney disease though you are at a risk of developing it in view of risk factors such as hypertension and elevated cholesterol. Treatment should focus on strict blood pressure control with medications; leading a healthy lifestyle including low salt diet, consumption of green leafy vegetables / fruits and regular exercise and continued management of elevated cholesterol while undergoing periodic testing for significant albumin and / or protein in urine.

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    What are the chances of fertility with a single testis?


    Q. I gave birth to a baby boy last year. During his birth, his testes had not descended properly. The doctor told us to wait for three months and see if they go down on their own. But in the middle of one and half months, one of the testes got twisted and lost its blood circulation. So, it had to be removed. At the same time we had brought down the other testis to the scrotum. Now everything is fine. I wanted to know if he should go for testis implantation. Now he is eight months old. The doctor said that the first implantation should be done at the end of nine months, the second one at the age of five years and the third one at the age of 15 years. Is the gap proper for the growth of scrotum? Kindly advise. Also, is the fertility with one testis similar to that with two? Does he need to take any precautions in future? Lastly, I would like to know the advantages and disadvantages of implantation.

    A. The chances of fertility with a single normal testis are similar to those males having two testes. The main concern should be whether or not the testis that has been brought down is normal. Many of the undescended testes are not completely normal. Protocol biopsy from the testis, done at the time of bringing the testis down, usually is able to tell whether the testis in question has a normal architecture. Functional normalcy of this testes, unfortunately, cannot be known until puberty. Testicular implants have only the cosmetic purpose. The implants have to be changed since the implants, unlike normal testes, cannot grow with age; and the implanted artificial testes look like silicone piece and should have a size close to its living and growing counterpart.

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    Can stem cell treatment help my son?


    Q. I have a 16 years old son. He has been getting seizures for more than 13 years. This has led to brain damage. Presently, he is on medication and the seizures are controlled. He is attending a special school. The attending doctors say that the child may have to take medicine throughout his life. Is it possible that in the near future with the help of stem cells, he is fully cured of this disease and the damaged part of the brain is repaired with the help of stem-cells?

    A. I am sorry to learn of your son's ailment and can well imagine the distress it is causing you.

    The seizure disorder in your son is likely related to the cause of the brain damage. There are several options for the long-term treatment of including drugs, ketogenic diet, and surgery in recalcitrant cases (hemispherectomy, focal resections, callosotomy & vagal nerve stimulation). These options are not mutually exclusive and can be used concurrently in the same individual and you could discuss this with your doctor. In many cases discontinuing medications is possible after a seizure-free period ranging from 2 years without seizures to after 4-5 years without seizures in persons with brain damage.

    Stem cells (or cells quite similar to them) have been identified in many different tissues of the body like neural, pancreatic, epidermal, mesenchymal, hepatic, bone, muscle, and endothelial tissues. Stem cell work is still quite experimental but is very promising as many beneficial therapies are thought to exist with much scientific value being ascribed to cord blood and its cells. Various centres in the world have been reporting their use in Parkinson’s disease, heart disease, endocrine disorders, etc. but this is still not being done routinely or being offered as a therapeutic modality. Human cord blood contains a large number of haematopoietic progenitor cells that can be used as a source of stem cells for treatment of blood disorders and cancers.

    Clinical efficacy is currently limited to bone marrow transplant, grafting new skin cells to treat burns, regenerating cornea in visually impaired, etc. Its potential use includes cures for cancer and treatment of neurologic, cardiac, renal, and endocrine (diabetes) diseases. There are still many difficulties in the routine use of stem cells and they include problem in identifying stem cells in tissue cultures, which contain numerous types of cells; to coax the cell to develop into a desired cell; integrating the new cells into the patient’s own tissue, both structurally and functionally; preventing tissue rejection and the possible risk of cancer. It is still not known what the effect of storing these cells for several decades would be as there have been no long term studies.

    Even though the potential is great, it will be a while before stem cell therapy can become a part of routine treatment.

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    Does my son need medical treatment?


    Q. I have 2 children. Both of them have a history of febrile convulsions at the age of 2. My son is now 11 years old. Ever since the attack, all these years, he jerks and twiches his legs and hands during his sleep. Is this associated with convulsions and does it require any treatment? An EEG was taken at the age of 8, but nothing was found. We are not sure what to do. The movements start during the initial period of sleep and last the whole night. Once he woke up suddenly and said he felt as if he fell from the cycle. Other wise he is an active child. Please guide us.

    A. Your child is likely having sleep myoclonus, which is not epilepsy. These are jerky movements that occur during certain stages of sleep and do not merit any treatment.

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