Yet another first at the National Hospital Colombo

By Rosanne Koelmeyer Anderson

Sri Lanka has recorded yet another feat in its medical history at the Colombo National Hospital by having successfully performed the first Endo Vascular Embolisation of Spinal Dural Arterio Venous Fistula procedure on a patient who was paralyzed waist downwards with bladder incontinence on Monday.

The forty-nine year-old Ranjith Gamage from Mawanella who was immobile and could not move or raise his legs was able to sit up, move and bend his lower limbs without any discomfort by the second day after the procedure. Ranjith who is now undergoing physiotherapy was overjoyed at the possibility of his being able to walk once again, sooner or later.

The condition which is congenial and comes with age causes loss of muscle power and gradually weakens. In this case the procedure was very difficult, Dr. Nihal Wijewardena, Consultant Interventional Radiologist told the Sunday Observer.

The Endovascular procedure, another alternative and much preferred procedure to that of surgery, was performed with a puncture in the femoral artery.

Before the procedure

after the procedure

With the help of a Guiding Catheter, micro catheter and a micro wire system the abnormal vessel in the spine is accessed and and those abnormal vessels are blocked using Cynoacrilate glue. Once the abnormal vessels are filled with this glue the blood flow to the spinal cord was regulated back to normalcy, Dr. Wijewardena explained.

“Promptly sitting up with a broad smile, Ranjith Gamage said” he was very relieved now as he was now able to move and bend his lower limbs quite comfortably making the procedure yet another feat for the doctors at NHS, Colombo.

“Meanwhile, on the same day yet another rare procedure was done by Dr. Wijewardena and Dr. Lakmalie Paranahewa with assistance of Prof. Santhosh Joseph, of Sri Ramachandra Medical School, Chennai and a team of dedicated anaesthetic doctors headed by Dr. Mrs. Hapuarachchi, and the neurosurgical team at NHSL on a patient with” a condition of cerebral aneurism; an Endovascular procedure which although could performed is not being done due to the simple reason of non availability “of necessary procedural equipment at the Colombo National Hospital as the cost ranges per case would cost between” Rs. 500,000 to over 1 million rupees depending on the size of the aneurism. In this case, the patient was agreeable to bear the cost for the procedure, while the procedure lasted about 4-5 hours, Dr. Wijewardena said.

“Endovascular procedure for Cerebral aneurism could be done in Sri Lanka like in other countries. Even the findings by” the “International Sub Arachnoid” (tm)s Trial (ISAT) conducted recently states that the Endovascular procedure has proved to be a much preferred procedure than brain surgery. But, in some instances brain surgery becomes inevitable.

“Endovascular procedure which involves the use of a Guiding catheter, a micro catheter, a micro guide wire and coils” which are sent after making a puncture in the groin of a patient. Thereafter, a micro catheter is introduced through the guiding catheter with the micro wire in to the aneurism. Coils are then introduced into the aneurism to stop the blood flow into it. The coils are very costly and “the number of coils needed depend on the size of the aneurism, Dr. Wijewardena further explained.”

“There are many patients with cerebral aneurism and it is more common among the 40-60 age group where the prevalence of degenerative diseases, Atherosclerosis and vascular diseases are high.

It could be classified as a stress related condition which could be triggered off any given time. It is uncommon in children. However, although the risk of rupture is difficult to determine precisely there is an estimated 1-2 per cent of cerebral aneurism ruptures per year,” (tm) he added.

“The aneurism raptures and there is haemorrhage then the patient has to be sorted out within 24 hours: there could be a high risk of re bleeding  and this could be fatal. Once bleeding has occurred an estimated 20-50 per cent risk of re bleeding is there within the first two weeks. Cerebral aneurism” could be detected during an incidental finding having complained of bouts of severe headache, weakness or loss of consciousness where initially a CT scan is done. If there is a bleed, an angiogram is also done to diagnose a cerebral aneurism. In 2007, three hundred and sixty cerebral angiograms were done at the National Hospital, Dr. Wijewardena added. Thus, having the necessary equipment at all given times is of great importance because the condition is most often life threatening.

However, an important yet unexploited procedure in Sri Lanka due to the high financial burden for the Ministry of Healthcare and Nutrition, this has nevertheless proved to be a vital decision and step forward for medical advancement.

The expertise is available but the equipment for the procedure is not, thus depriving many patients suffering from cerebral aneurism of availing themselves of the more plausible alternative, compelling them to go in for brain surgery.

Breastfeeding - the first 6 months of life

Increasing optimal breastfeeding practices could save an estimated 1.5 million infant lives annually. Up to 55 percent of infant deaths from diarrhoeal disease and acute respiratory infections may result from inappropriate feeding practices. Optimal feeding for sustained child health and growth includes initiation of breastfeeding within the first hour of life, exclusive breastfeeding for six months, timely complementary feeding with appropriate foods, and continued breastfeeding for two years and beyond.

During the first 6 months of life, infants should be

exclusively breastfed. This means that the healthy baby should receive breastmilk and no other fluids, such as water, teas, juice, cereal drinks, animal milk or formula.

Exclusively breastfed babies are much less likely to get diarrhoea or to die from it than are babies who are not breastfed or are partially breastfed. Breastfeeding also protects against the risk of allergy early in life, aids in child spacing and provides protection against infections other than diarrhoea (e.g. pneumonia). Breastfeeding should be continued until at least 2 years of age.

The best way to establish the practice is to put the baby to the breast immediately after birth and not to give any other fluids.

Advantages and benefits of breastfeeding are listed below. Some or all of them may be explained to mothers using simple language.

If breastfeeding is not possible, cow’s milk or milk formula should be given from a cup.

This is possible even with very young infants. Feeding bottles and teats should *never* be used because they are very difficult to clean and easily carry the organisms that cause diarrhoea.

Careful instructions should be given on the correct preparation of milk formula using water that has been boiled briefly before use.

Advantages and benefits of breastfeeding

1. Saves Lives Currently there are 9 million infant deaths a year. Breastfeeding saves an estimated 6 million additional deaths from infectious disease alone.

2. Provides Initial Immunization. Breastmilk, especially the first milk (colostrum), contains anti-bacterial and anti-viral agents that protect the infant against disease, especially diarrhoea. These are not present in animal milk or formula. Breastmilk also aids the development of the infant’s own immune system.

3. Prevents Diarrhoea Diarrhoea is the leading cause of death among infants in developing countries. Infants under two months of age who are not breastfed are 25 times as likely to die of diarrhoea than infants exclusively breastfed. Continued breastfeeding during diarrhoea reduces dehydration, severity, duration, and negative nutritional consequences of diarrhoea.

4. Provides complete and perfect nutrition.

Breastmilk is a perfect food that cannot be duplicated. It is more easily digested than any substitute, and it actually alters in composition to meet the changing nutritional needs of the growing infant. It provides *all* the nutrients and water needed by a healthy infant during the first 6 months of life. Formula or cow’s milk may be too dilute (which reduces its nutritional value) or too concentrated (so that it does not provide enough water), and the proportions of different nutrients are not ideal.

5. Maximizes a child’s physical and intellectual potential.

Malnutrition among infants up to six months of age can be virtually eradicated by the practice of exclusive breastfeeding. For young children beyond six months, breastmilk serves as the nutritional foundation to promote continued healthful growth. Premature infants fed breastmilk show higher developmental scores as toddlers and higher IQs as children than those not fed breastmilk.

6. Promotes the recovery of the sick child.

Breastfeeding provides a nutritious, easily digestible food when a sick child loses appetite for other foods. When a child is ill or has diarrhoea, breastfeeding helps prevent dehydration. Frequent breastfeeding also diminishes the risk of malnutrition and fosters catch-up growth following illness.

7. Supports food security. Breastmilk provides total food security for an infant’s first six months. It maximizes food resources, both because it is naturally renewing, and because food that would otherwise be fed to an infant can be given to others.

A mother’s milk supply adjusts to demand; only extremely malnourished mothers have a reduced capacity to breastfeed.

8. Bonds mother and child. Breastfeeding immediately after delivery encourages the “bonding” of the mother to her infant, which has important emotional benefits for both and helps to secure the child’s place within the family. Breastfeeding provides physiological and psychological benefits for both mother and child.

It creates emotional bonds, and has been known to reduce rates of infant abandonment.

Silent treatment or poor communication?

Tips before you talk to a doctor:

By Dr. R. A. R. Perera, Consultant Psychologist

These days many doctors are responding to patients demand for better communication. A doctor cannot be fully competent if they don’t communicate effectively with their patients.

Far too often the ‘first wake-up call’ comes from a patient who complains about the medical care they have received. In fact, underlying many, and perhaps most complaints, is the fact that the doctor failed in some communication dimension, rather than in some more technical aspect of the care.

Numerous surveys show the need for more effective doctor-patient communications even though many physicians excel in this field. Yet, even as a shortage of physicians is increasing and case loads are getting heavier, patients are becoming more educated about health issues. They are demanding better communication between themselves and their physicians and others in the health-care industry. It’s become a crucial issue.

Generally, most patients are pretty efficient at telling their own stories. A doctor being on time to see patients is probably the best way to keep them happy although this is difficult with urgent calls and hospital and other commitments.

A physician may miss critical things if the patient is nervous and don’t really wish to say something about him or her.

Here are few tips on how to get the best from a consultation with your physician:

* Think about what seems to be wrong. When did it start? What are the symptoms? How bad is the pain on a scale 1-10.

* Write down brief details on a single page along with medical history, any medications being taken the dosage and frequency. Give the page to the doctor and keep a copy for yourself.

* List questions to ask before you arrive for your appointment. Describe your problem verbally and concisely. If you are too embarrassed to talk, write it down or hand over a relevant page from a magazine.

* Take someone with you if you feel that’s useful. Write down what you have been told by your physician as soon as you go home.

* Speak up if there is any examination, procedure or medical jargon that you do not understand. It is the doctor’s duty to explain to you in simple language, the problems you have and what he is going to do about it.

In Sri Lanka some doctors due to lack of time do not perform this, but it is not an excuse. In countries like England, United States and in Canada a doctor can be sued for not letting the patient know his or her problem in simple language where the patient could understand his or her medical situation.

* If you are sick, or need to talk over something, visit your family doctor first and get a referral letter, without straight going to a specialist.

* Make sure that you are informed of the results of any tests, scans or X-rays, which are done, in your subsequent visit.

* Don’t waste the doctor’s time by telling unnecessary things if you think it is not relevant to your present medical or psychological problem, unless the doctor ask about it.

The number I think is that a doctor should treat his patient the way he (the doctor) liked to be treated if he goes to a physician. A doctor should be straightforward and clear in discussing a medical situation and has to show genuine interest in the patient and his family, even when very busy.

One thing medical schools are stressing more than ever is the need for doctors to refrain from using medical jargon that patients, might not understand.

After medical credentials a patient like his or her doctor to have a sense of humour, the ability and desire to listen, professionalism, a friendly staff and well kept waiting room, clean fingernails and ability to apologize for running late and if possible call and tell patients that their appointments will be delayed.

Breastfeeding

Best for baby Reduces incidence of allergies Economical - no waste Antibodies - greater immunity to infections Stool inoffensive - never constipated Temperature always correct and constant Fresh milk - never goes sour in the breast Emotionally bonding Easy once established Digested easily within two to three hours Immediately available Nutritionally balanced Gastroenteritis greatly reduced.