NIGHT TIME URINATION: NIGHTMARE FOR ELDERLY PEOPLE

Night time urination i.e. nocturia is defined as getting up for multiple times in the night to pass urine.

This is a disturbing development as it can interrupt the sleep and make the person lethargic and drowsy the whole day and also it can have more serious implications like  falls while running to bathroom in the darkness. Nocturia can lead to disturbed sleep and disturbed sleep can lead to nocturnal urination. These two things are often interwoven.Proper  history is must to help people who have disturbed sleep and hence they pass urine in the night.They usually don't have any medical illnesses causing nocturnal polyuria and also they don't have any altered bladder function.

Nocturia can be because of various reasons from the physiological ones like drinking a lot of water in the evening ( habitual polydipsia) or serious pathological disorders like congestive cardiac failure, hyperparathyroidism,benign prostatic hyperplasia,bladder infection,interstitial cystitis,chronic renal failure etc. The sleep apnoea syndrome also is one of the causes of nocturia.

In elderly people the nocturnal is very common, the prevalence reaching to 80% in above years age group.It has been found that the elderly people have more than 33% urine output in the night time although the whole day urine output remains the same.The  anti-diuretic hormone levels are low in the night time in the elderly.In the elderly there is also decreased renal function, prostatomegaly and disturbed sleep pattern.These all factors lead to accentauation of nocturnal urination. 

The patients need a thorough evaluation to rule out the underlying disorders.A proper voiding dairy , urine routine and culture,USG KUB and PVR ,uroflowmetry and urodynamic studies etc are needed in cases where medical causes have been ruled out.
A  dedicated history, voiding diary,meticulous examination( including Focussed neurological Examination), involvement of physician and directed tests ( as per the merits of the case)  helps in coming to conclusion and help in proper management.

Interventions:

• Restrict fluids in the evening (especially coffee, caffeinated beverages, and alcohol).
• Time intake of diuretics (take mid- to late afternoon, six hours before bedtime).
• Take afternoon naps.
• Elevate the legs (helps prevent fluid accumulation).
• Wear compression stockings (helps prevent fluid accumulation).

Medications:

• Anticholinergic medications: reduce symptoms of overactive bladder
• Bumetanide (Bumex), Furosemide (Lasix): diuretics that assist in regulating urine production
• Imipramine (Tofranil): decreases urine production
• Desmopressin (DDAVP): helps the kidneys produce less urine.

Desmopressin, a synthetic antidiuretic hormone analogue, is the only drug currently approved for the treatment of nocturia associated with nocturnal polyuria or multiple sclerosis (MS). Compared with vasopressin, desmopressin has a longer lasting and more potent antidiuretic effect and is devoid of vasopressor and uterotonic effects. In two large, randomised, double-blind phase III trials in adults with nocturia associated with nocturnal polyuria, 3 weeks of oral desmopressin therapy was significantly more effective than placebo in reducing the mean number of nocturnal voids and in normalising the rate of nocturnal urine production. Beneficial effects of desmopressin on nocturia were maintained and increased in patients completing 10 or 12 months of further treatment in a non-blind extension of short-term trials.

Surgical management:

In select cases Prostatectomy can help.

PCNL IN LOWER CALYCEAL STONE

A 45y male presented with rt flank pain and was found to have Rt lower calyceal stone of around 3 cm size. He was taken up for RT PCNL through lower calyceal puncture. A 20.5F 20 cm Wolf nephroscope was used and the tract was dilated till 24 f. Complete clearance was achieved. Postop period was uneventful and was discharged in a stable condition.

PCNL IN MALROTATED KIDNEY

A 35 y man presented with left flank pain and was found to have left malrotated kidney and multiple large renal calculi with hydronephrosis. He was taken up for PCNL. Complete clearance was achieved by the use of mini nephroscope and flexible nephroscope. Patient recovered fully and was discharged in  a stable condition.

                                    

EMERGENCIES ALL SHOULD KNOW:HYPOGLYCEMIA(LOW SUGAR LEVEL)

HYPOGLYCEMIA(LOW SUGAR LEVEL)
                                           

Hypoglycemia is a condition where there is abnormally low blood sugar (glucose) in blood.The problems arise from inadequate supply of glucose to the brain,resulting in giddiness,siezures,un-consciousness ,brain damage occasionally death.

                                         

Hypoglycemia occurs most commonly in diabetics on either insulin or oral hypoglycemia drugs.The Hypoglycemia is less common in non-diabetic persons, but can occur at any age. 

 The other causes include  excessive insulin produced in the body as in insulinoma,inborn errors of metabolism,some medications,poisons,alcohol,hormone deficiencies, prolonged starvation, alterations of metabolism associated with infection, and organ failure.

                                    

It is often self-diagnosed in experienced diabetics and self-medicated orally by the ingestion of balanced meals.Hypoglycemia is treated by restoring the blood glucose level to normal by the ingestion or administration of dextrose or carbohydrate foods.  In more severe circumstances, it is treated by i.v glucose,injection or infusion of glucagon. Recurrent hypoglycemia may be prevented by reversing or removing the underlying cause, by increasing the frequency of meals, with medications like diazoxide, octreotide, or glucocorticoids, or by surgical removal of part  of  pancreas.

The level of blood glucose low enough to define hypoglycemia may be different for different people, in different circumstances, and for different purposes, and occasionally has been a matter of controversy. Most healthy adults maintain fasting glucose levels above 4.0 mmol/l (72 mg/dl), and develop symptoms of hypoglycemia when the glucose falls below 4 mmol/L. It can sometimes be difficult to determine whether a person's symptoms are due to hypoglycemia. Criteria referred to as whipples triad are used to determine a diagnosis of hypoglycemia:

1. Symptoms known to be caused by hypoglycemia
2. Low glucose at the time the symptoms occur
3. Reversal or improvement of symptoms or problems when the glucose is restored to normal.

                                           

1. Blood glucose levels  usually are venous plasma or serum levels measured by standard, automated glucose oxidase methods used in labs. 

1.  The whole blood glucose levels measured by finger prick methods  using glucometer are about 10%-15% lower than venous plasma levels.
2. The delay that occurs when blood is drawn at a satellite site and transported to a central laboratory hours later for routine processing is also another common cause of falsely low glucose levels.
3. Children's blood sugar levels are often slightly lower than adults'. Overnight fasting glucose levels are below 70 mg/dL (3.9 mM) in 5% of healthy adults, but up to 5% of children can be below 60 mg/dL (3.3 mM) in the morning fasting state.

                                        

1.  Hormonal defence mechanisms like adrenaline,glucagon are normally activated as it drops below a threshold level (about 55 mg/dL (3.0 mM) for most people), producing the typical hypoglycemic symptoms of shakiness.
2. In newborns, hypoglycemia can produce irritability, jitters, jerks,,cyanosis, respiratory distress, apneic episodes, sweating, hypothermia, somnolence,  refusal to feed, and seizures or "spells.
3. Hypoglycemic symptoms can also occur when one is sleeping. Examples of symptoms during sleep can include damp bed sheets or clothes from perspiration. Having nightmares or the act of crying out can be a sign of hypoglycemia. Once the individual is awake they may feel tired, irritable, or confused and these may be signs of hypoglycemia as well.
4.                              
5. In nearly all cases, hypoglycemia that is severe enough to cause seizures or unconsciousness can be reversed without obvious harm to the brain.
6. The circumstances of hypoglycemia provide most of the clues to diagnosis. Circumstances include the age of the patient, time of day, time since last meal, previous episodes, nutritional status, physical and mental development, drugs or toxins (especially insulin or other diabetes drugs), diseases of other organ systems, family history, and response to treatment. It may take longer to recover from severe hypoglycemia with unconsciousness or seizure even after restoration of normal blood glucose.
7. The risk of further episodes of diabetic hypoglycemia can often (but not always) be reduced by lowering the dose of insulin or other medications, or by more meticulous attention to blood sugar balance during unusual hours, higher levels of exercise, or decreasing alcohol intake.

                                         

1. Treatment of some forms of hypoglycemia, such as in diabetes, involves immediately raising the blood sugar to normal through the ingestion of carbohydrates
2. It can be taken as food or drink if the person is conscious and able to swallow. This amount of carbohydrate is contained in about 3–4 ounces (100–120 ml) of orange, apple, or grape juice although fruit juices. the "rule of 15" – consuming 15 grams of carbohydrate followed by a 15 minute wait, repeated if glucose remains low . in-hospital personnel can establish IV access and give intravenous dextrose, concentrations varying depending on age (infants are given 2 ml/kg dextrose 10%, children are given dextrose 25%, and adults are given dextrose 50%).

                                            

Prevention of hypoglycemia is better way than treating it.Keep A WATCH ON YOUR DIET AND INSULIN.
more in blog:

ACUTE PAIN ABDOMEN

HAEMETEMESIS

THROMBOSED,PAINFUL PILES

ACUTE TUBULAR NECROSIS

PARAPHIMOSIS

TESTICULAR TORSION

TRAUMA

RENAL COLIC

PRIAPISM

ACUTE URINE RETENSION

SEVERE PALLOR

ABSCESS

ANIMAL BITES

POISONING

BURNS

SEIZURES

PARALYTIC STROKE

ANY PREGNANCY RELATED EVENT

SUDDEN LOSS OR IMPAIRMENT OF VISION

SUDDEN HEAD ACHE AND VOMITING

HIGH GRADE FEVER

NON-RESPONSIVENESS

VIOLENT BEHAVIOUR

SUDDEN CALF PAIN

SEVERE BREATHLESSNESS

SINGLE DOSE CARBOPLATIN THERAPY FOR STAGE 1 SEMINOMA TESTIS

A 32 year old gentleman presented to us with painless  testicular mass.He had normal tumor markers.

He was taken up for high inguinal orchiectomy. The final histopathological report showed the mass to be seminoma.

His PET-CT was normal.We gave him three options for further treat( as the staging was stage 1 seminoma):

1) Radiotherpy

2) Single dose carboplatin chemotherpy

3)Active surveillance

The single dose chemotherapeutic regimen was  finally given to the patient after he agreed for the same.We explained him the pros and cons of all the modalities.

SINGLE DOSE CHEMOTHERAPY FOR STAGE 1 SEMINOMA:

Traditionally radiotherapy has been routinely given for the patients of stage 1 seminoma. But there are many concerns about the radiotherapy:

1) about 1/3 of the relapses are outside the radiotherapy field

2)The cardiovascular side effects

3)the likely hood of recurrence of non germ cell cancer

Active surveillance is a good option to avoid the side effects of radiotherapy but is associated with 15-20% relapse rate.Many patients are somewhat dissatisfied about " no adjuvant therapy" and live under fear.It also needs dedicated follow-up.

But the single dose chemotherapy appears appealing ( as its adjuvant therapy and convenient also).There was a randomised trial conducted by Oliver et al..

Around 1477 patients were enrolled for radiotherapy and single dose chemotherapy by carboplatin  ( 1996 -2001 from 70 hospitals in 14 countries).The groups were followed up for 4 years.The relapse rate in bothe the groups were comparable.It was also interesting to see the group which received carboplatin were less lethargic and took less time off from daily  day to day activities.As most of the patients with    carcinoma testis are young; professional work related issues hold a lot of importance in their life.  

 

A single dose of carboplatin appears to be as effective as adjuvant radiotherapy in preventing disease recurrence among men with stage 1 seminoma after orchiectomy. In an abstract presented here at the American Society of Clinical Oncology (ASCO) 44th Annual Meeting, researchers reported that carboplatin was also significantly more effective than radiotherapy in preventing contralateral testicular germ-cell cancers.   

EMERGENCIES ALL SHOULD KNOW:EPISTAXIS(BLEEDING THROUGH NOSE)

EPISTAXIS(BLEEDING THROUGH NOSE)


Epistaxis is the relatively common occurrence of bleeding from the nose, usually noticed when the blood drains out through the nostrils. There are two types: anterior (the most common), and posterior (less common, more likely to require medical attention).


 Sometimes in more severe cases, the blood can come up the naso-lacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting It is rarely fatal.The causes of nosebleeds can generally be divided into two categories, local and systemic factors, although a significant number of nosebleeds occur with no obvious cause.


Among local factors,trauma,foreign body or local infections are responsible for bleeding through nose.Anatomical deformities like septal spur,drugs like cocaine,nasal tumours,low humid conditions(cold winter),ear baro trauma due to descent of aircraft,ascent in scuba diving)etc

Systemic causes include hypertension,bleeding disorders,patients on anti-coagulants,aspirin etc.
Nosebleeds are due to the rupture of a blood vessel within the richly perfused nasal mucosa.An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis.Anti-coagulant medication and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure tends to be higher. The elderly are also more prone to prolonged nose bleeds as their blood vessels are less able to constrict and control the bleeding.

The vast majority of nose bleeds occur in the anterior (front) part of the nose from the nasal septum. This area is richly endowed with blood vessels. This region is also known as Littles area. Bleeding farther back in the nose is known as a posterior bleed and is usually due to bleeding from Woodruff's plexus, a venous plexus situated in the posterior part of inferior meatus. Posterior bleeds are often prolonged and difficult to control. They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth.

The flow of blood normally stops when the blood clots, which may be encouraged by direct pressure applied by pinching the soft fleshy part of the nose.Pressure should be firm and be applied for at least five minutes and up to 20 minutes; tilting the head forward will help decrease the chance of nausea and airway obstruction. Swallowing excess blood can irritate the stomach and cause vomiting.

 

The local application of a vasoconstrictive agent has been shown to reduce the bleeding time in benign cases of epistaxis. The drugs oxymetazoline or phenylephrine are widely available in over-the-counter nasal sprays.If these simple measures do not work then medical intervention may be needed to stop bleeding. In the first instance this can take the form of chemical cautery of any bleeding vessels or packing of the nose with ribbon gauze or an absorbent dressing (called anterior nasal packing)This is a painful procedure and the nasal mucosa should be anaesthetised first, and performed by experts.

Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anaesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose.Application of a topical antibiotic ointment to the nasal mucosa has been shown to be an effective treatment for recurrent epistaxis.

There is  Japanese folk belief according to which nosebleeds are signs of sexual excitement. (Interestingly, the nose is now known to contain erectile tissue which may become engorged during sexual arousal:honeymoon rhinitis is a condition in which nasal stuffiness or sneezing accompanies sexual thoughts or activities).There is increased incidence of epistaxis in high altitude due to low atmospheric pressure.

more in blog:

HYPOGLYCEMIA

ACUTE PAIN ABDOMEN

HAEMETEMESIS

THROMBOSED,PAINFUL PILES

ACUTE TUBULAR NECROSIS

PARAPHIMOSIS

TESTICULAR TORSION

TRAUMA

RENAL COLIC

PRIAPISM

ACUTE URINE RETENSION

SEVERE PALLOR

ABSCESS

ANIMAL BITES

POISONING

BURNS

SEIZURES

PARALYTIC STROKE

ANY PREGNANCY RELATED EVENT

SUDDEN LOSS OR IMPAIRMENT OF VISION

SUDDEN HEAD ACHE AND VOMITING

HIGH GRADE FEVER

NON-RESPONSIVENESS

VIOLENT BEHAVIOUR

SUDDEN CALF PAIN

SEVERE BREATHLESSNESS

EMERGENCIES ALL SHOULD KNOW:FOREIGN BODY

FOREIGN BODY:
 Foreign bodies involve propulsion through natural orifices into hollow organs.Foreign bodies can be inert or inflammatory causing inflammation and scarring. They can precipitate infection into the body or acquire infectious agents. They can obstruct passages either by their size or by the scarring they cause. Some can be toxic.

Young children, in particular, are naturally curious and may intentionally put shiny objects, such as coins or button batteries, into their mouths. They also like to stick things in their ears and up their noses.

Although ingested non-magnetic foreign bodies are likely to be passed spontaneously without consequence, ingested objects (magnetic toys) may attract each other through children's intestinal walls and cause severe damage, such as pressure necrosis, perforation, intestinal fistulas, volvulus, and obstruction.


It is possible for foreign bodies to enter the tract from the mouth, or from the rectum.It is also possible for a foreign body to enter the airways and cause choking.Among foreign bodies,peanuts were the most common obstruction.Foreign body in the bronchi can also present as chronic cough.Airborne particles can lodge in the eyes of people at any age. These foreign bodies often result in allergies which are either temporary or even turn into a chronic allergy. This is especially evident in the case of dust particles.With sufficient force (as in firing of bullets), a foreign body can become lodged into nearly any tissue. splinters are common foreign bodies in skin.staphylococcus  infection often causes boils to form around them.Tetanus prophylaxis may be mandatory.

Foreign bodies can also be found in eyes,nose,ear,vagina,urethra,blood vessels etc.Foreign bodies are common injuries to eyes in workshop setups for the employees.Foreign bodies are self introduced into rectum,urethra and vagina by some males and females who suffer from abnormal sexual fantasies. Some patients suffer from psychiatric illness and have abnormal eating habits including hair,metal objects,etc.


Medical specialists use cystoscope,endoscope,colonoscope, bronchoscope,and specialised forceps and equipments to remove foreign bodies from various areas.Sometimes major open surgeries are needed in abdominal foreign bodies.
more in blog:

EPISTAXIS

HYPOGLYCEMIA

ACUTE PAIN ABDOMEN

HAEMETEMESIS

THROMBOSED,PAINFUL PILES

ACUTE TUBULAR NECROSIS

PARAPHIMOSIS

TESTICULAR TORSION

TRAUMA

RENAL COLIC

PRIAPISM

ACUTE URINE RETENSION

SEVERE PALLOR

ABSCESS

ANIMAL BITES

POISONING

BURNS

SEIZURES

PARALYTIC STROKE

ANY PREGNANCY RELATED EVENT

SUDDEN LOSS OR IMPAIRMENT OF VISION

SUDDEN HEAD ACHE AND VOMITING

HIGH GRADE FEVER

NON-RESPONSIVENESS

VIOLENT BEHAVIOUR

SUDDEN CALF PAIN

SEVERE BREATHLESSNESS

EMERGENCIES ALL SHOULD KNOW:BRONCHOSPASM(WHEEZING)

BRONCHOSPASM(WHEEZING)
 Bronchospasm is a sudden constriction of the muscles in the walls of the bronchioles causing  difficulty in breathing which can be very mild to severe.

Bronchospasms are seen in Asthma, chronic bronchitis anaphylaxis etc. Bronchospasms also associated  with cold housing.Some of the things that can cause bronchospasms are consuming allergy prone foods,  getting insect bites or stings when one is allergic to them, and rarely  fluctuating hormone levels, particularly in women.

A few of the more common allergens are foods such as eggs, milk, peanuts, walnuts, tree and other nuts, fish, especially shellfish, soy and wheat; insect bites and stings, especially bee stings; and other medicines, especially penicillin and its derivatives, inhalation of pollen,dust,  animal dander,molds cigarette smoke,aerosol spray etc..

Bronchospasm is associated with narrowing of the airways and an increase in sticky mucus production not able to cough out; this reduces the amount of oxygen that is available to the individual causing breathlessness, coughing and hypoxia.Wheezing is a whistling sound that occurs during breathing, usually during expiration (breathing air out of the lungs) through narrowed airways. 

Exercise is a common trigger for wheezing in children.Psychological stress also triggers bronchospasm.Respiratory tract infections can induce bronchospasm as a part of inflammatory reaction to bacteria,virus etc.

Bete 2 agonists are treatment of choice to relieve bronchospasm.They are available as both oral medications and inhalers.To reduce the associated inflammation,steroids and cromolyn sodium are also used for speedy relief from bronchospasm.

Encourage the child to drink more water and other liquids to make the mucus thin and easy to be coughed out.I.V antibiotics are to be started in case of fever and wheezing.

A detailed history related to foreign body inhalation/ingestion is mandatory as it is easily missed out correctable cause of bronchospasm in children. If a foreign body is suspected, bronchoscopy is done to see and remove the foreign body.
more in blog:

FOREIGN BODY(AIRWAY)

EPISTAXIS

HYPOGLYCEMIA

ACUTE PAIN ABDOMEN

HAEMETEMESIS

THROMBOSED,PAINFUL PILES

ACUTE TUBULAR NECROSIS

PARAPHIMOSIS

TESTICULAR TORSION

TRAUMA

RENAL COLIC

PRIAPISM

ACUTE URINE RETENSION

SEVERE PALLOR

ABSCESS

ANIMAL BITES

POISONING

BURNS

SEIZURES

PARALYTIC STROKE

ANY PREGNANCY RELATED EVENT

SUDDEN LOSS OR IMPAIRMENT OF VISION

SUDDEN HEAD ACHE AND VOMITING

HIGH GRADE FEVER

NON-RESPONSIVENESS

VIOLENT BEHAVIOUR

SUDDEN CALF PAIN

SEVERE BREATHLESSNESS