TYKF-AABMSS MONTHLY MEDICAL FORUM 247-252

Medical Forum No. 247
Brachial Plexus Injuries
Discussant: Emmanuel Estrella, M.D.

Brachial plexus is a complex network of nerves arising from cervical roots 5 to 8 (C5-C8) and  the first thoracic root (T1). These nerves are responsible for the sensation and movement of the upper extremity.

Brachial plexus injuries may involve some or all of the nerves of the plexus and will result in dysfunction. Injuries involve some nerves and may include symptoms such as weakness or paralysis of the shoulder, elbow and hands, depending on which of  the nerve roots are involved. In cases where all five nerves are involved, the whole upper extremity, from shoulder to the hands may lose sense of touch and may be paralyzed.

Types of Brachial plexus injuries include:

• Adult Traumatic: usually caused by either a stretched, ruptured or an avulsion type of injury, common in high-speed motor vehicular accidents. Prognosis would depend on severity of injury.
  
• Obstetric: injuries that result from difficulty delivering larger and heavier babies. The shoulder usually gets trapped during child birth.
  

Treatment options include:

• Surgery, when no recovery is expected. It ranges from the simplest to the most complex, depending on the severity of nerve injury.
  
• In early cases (less than sic months from injury), surgery is most effective.  This includes exploration of brachial plexus and nerve reconstruction.
  
• In late cases, salvage procedures such as tendon-muscle transfers and selected fusions are done.
  

There are cases, however of spontaneous recovery.

Medical Forum No. 248
Robotic Assisted Surgery for the
Treatment of Prostate Cancer
Discussant: Jason L. Letran, M.D.

The prostate is a small, walnut-sized structure that makes up part of a man’s reproductive system. It wraps around the urethra, the tube that carries urine out of the body. 

Treatment options for localized prostate cancer include: 

• Traditional open surgery, which requires a large eight to ten inches of incision.  The open surgery is done to remove the entire malignant prostate and its nearby structures.  This procedure is potentially associated with more blood loss and longer recovery period.  
  
• Robotic Assisted Prostatectomy, utilizes the state-of-the-art technology device called the “DA VINCI ROBOT”. This allows the surgeon to see vital anatomical structures inside the body more clearly and to perform more precise surgery. It  utilizes only small keyhole incisions that markedly decreases the degree of invasiveness. This results to:
  
• Less post-operative pain n Less risk of infection
  
• Less scarring
  
• Less blood loss and transfusions
  
• Shorter hospital stay n Faster recovery and quicker return to normal activities 
  

Medical Forum No. 249
Understanding 
(De-mystifying) Lupus
Discussant: Julie Li-Yu, M.D.

Systemic lupus erythematosus is a complex, prototypic, multisystemic, autoimmune disease associated with pathogenic autoantibodies resulting in immune complex deposition and complement tissue damage. 

The incidence of Lupus affects:

• Around 500,000 to 1.5 million Americans have lupus with an escalation of 16,000 people each year.
  
• Children, teenagers and elderly men and women can get lupus. However, 80-90% of lupus patients are females of childbearing years between 15 and 45 years old.
  
• Lupus disproportionately affects people of different races. African-American women are three times more likely than Caucasian women to be affected by lupus.
  

No single known cause is identified, but Lupus might be triggered by a combination of the following:

• Genetics plays a major role in the disease process. There may be as many as 100 genes which contribute to the development of systemic lupus erythematosus.
  


• Hormones cause an overactive immune system, which is a hallmark of Lupus. Female hormones tend to stimulate an immune response. Male hormones have the opposite effect and are more immunosuppressive.
  


• Environment plays a role in initiating or triggering lupus in a genetically-predisposed person. These factors include ultraviolet light(sunlight and fluorescent light), extreme stress, infectious agents such as viruses, certain foods or chemical agents, and certain medications such as those belonging to the sulfa and penicillin groups.
  

Symptoms may embrace a wide scope: 

• can come and go and are usually vague and often mimic other illnesses;
  


• may be acute, resembling an infectious process consisting of fever, pleurisy and muscle aches or they may be a progression of vague symptoms over a long period of time;
  


• Surgery can also exacerbate lupus symptoms. Elective surgeries should not be performed until lupus activity subsides. Passive immunizations have not been shown to exacerbate systemic lupus erythematosus. However, live vaccines are not advisable.
  


• Emotional changes such as grief, depression, and anger, can make a person feel isolated from others.
  

Diagnosis usually involves professional readings of Internists, Dermatologists, Nephrologists, Rheumatologists. The diagnosis requires:

• entire medical history (including family history) 
  


• analysis of laboratory tests
  


• complete physical examination 
  


• biopsy of the skin or kidney
  

An open mind and good communication are necessary in assessing the patient.

Treatment options can minimize symptoms, reduce inflammation, and maintain normal body functions. The choice of drugs is highly individualized and often changed during the course of the disease. Drugs include NDAIDS, anti-malarials, corticosteroids, immunosuppressants, and all coupled with investigational research.

Management of persons afflicted with Lupus should:

• become well educated about the disease;
  


• learn how to detect early symptoms of disease activity, which can help the physician know when a change in treatment is needed and to prevent the onset of a lupus flare; (Warning signs of a flare include increased fatigue, pain, rash, fever, stomach discomfort, headache and/or dizziness.)
  
•  listen and acknowledge these subjective complaints because they provide a sense of comfort to the patient;
  


• maintain healthy relationships for patients, ask for support by keeping clear lines of open communication with family, friends, health care providers to alleviate and manage stress, depression and pain.
  

Prognosis is much better today, but a cure for Lupus has not yet been developed and causes death.  Those patients with non-organ threatening form of the disease can look forward to a normal lifespan if they follow instructions of physicians, take medication(s) as prescribed, and seek help for unexpected side effects of a medication or any new symptoms. 


Medical Forum No. 250
COPD: The Silent Killer
Discussant: Dennis Teo, M.D.

Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable, and treatable disease. It is a chronic inflammatory response in the airways and the lung to noxious particles or gases. Around 20% to 25% of the world sample population has COPD and is now the fourth leading cause of death.

Causes of the disease include prolonged years of exposure to tobacco smike and long-term exposure to noxious fumes, gases, and wood fire particles, biomass fuels, and other work-related dust.

Characteristics marked generally by progressive chronic airflow limitation include:

• a mixture of small airways disease (chronic obstructive bronchiolitis) and parenchymal destruction (emphysema);
  


• a genetic predisposition on which phenotype a person belongs to( new medications are shown to benefit certain phenotypes of chronic bronchitis);
  
•  neutrophilic inflammation in the airways and alveoli.
  


• The airways are narrowed, edematous, and the ciliated columnar cells are distorted, losing its important function of moving foreign substances and secretions out of the lungs.
  


• Damaged alveoli affects gas exchange in and out of the body causing blood gas abnormalities of hypoxemia and hypercapnea. These changes are not fully reversible.
  


• Patients are predisposed to recurrent exacerbation of COPD as well as infection. 
  
•  Inflammation is not confined to the lungs. It also systemically involves other organs. Patients are predisposed to developing ischemic heart problems, muscle apoptosis and wasting, gastrointestinal, neurologic and renal failure problems.
  

Diagnosis is done  clinically coupled with spirometry. It looks out for:

• symptoms of chronic dyspnea or breathlessness at rest and on exertion;
  


• chronic sputum production of more than 3 months for two consecutive years;
  


• history of chronic exposure to noxious substances
  

Forms of treatment are mostly given for symptomatic relief.  They include:

• Drugs: new medications with prolonged effects; improved drug delivery directly targets inflammation in the lungs. These are: bronchodilators, which open up the airways; steroids, which decrease inflammation; mucolytics, which assist in expectoratin; and provision of oxygen, which improves gas exchange.  Vaccinations to protect from deadly serotypes of streptococcus and influenza are also administered.  
  

CPAP and BiPAP improve hypercapnea for patients whose CO2 elevation is more of the problem and result to:

• pulmonary rehabilitation such as  teaching breathing exercises to help patients get back their life;
  


• improve nutrition of emphysema patients;
  


• lung volume reduction surgery:, which is an option for localized emphysema patients such as lobectomy and bullectomy.
  

Lung transplant has had some success cases, but with the difficulty of finding lung donors, high cost, and rejection in lung transplants have hindered its progress in the Philippines.

Prevention includes smoking cessation and using wood fire and biomass fuel as well as wearing protective gear if exposure in the workplace is inevitable.


Medical Forum No. 251
Dengue: Living Dengue-rously
Discussant: Richmond Reyes, M.D.

Dengue Fever is an acute febrile illness caused by any one of the four serologically-related RNA virus (DEN-1, DEN-2, DEN-3, DEN-4), with an incubation period of three to fifteen days(average of five to eight days). Mode of transmission is a bite of the Aedes aegypti mosquito (daybiting) and peak periods are early in the morning and in the evening before dusk.

The incidence of dengue is the most rapidly spreading mosquito-borne viral infection affecting people of all ages in the world, with an estimated 25,000 deaths occurring each year. It is most prevalent in tropical and sub-tropical areas including the Philippines.  Dengue has become a whole-year-round disease in recent years with cases seeing a surge since 2009.

The course of the illness takes about two to seven days of febrile phase and the critical phase, which usually lasts for 24 to 28 hours and occurs during the third to seventh day of illness when fever subsides.  

Symptoms include: 

• fever, headache, body malaise, “flu-like illness” such as muscle and joint pains;
  


• poor appetite, nausea, vomiting, diarrhea, problem of dehydration or seizure in children;
  


• rashes and mucosal membrane bleeding (ex. nose or gums) may be present.
  

Diagnosis is done through CBC tests and positive result would should decreased WBC with or without a decrease in platelet count. Optional tests are Dengue NS-1 antigen test, which is best done during the first four days of fever, and Dengue lgM antibody test.

Patients with warning signs may deteriorate, while patients without warning signs may improve.  Warning signs include:

• severe plasma leakage leading to shock (Dengue Shock) with or without respiratory distress;
  


• severe bleeding and/or severe organ impairment; n mucosal bleeding;
  


• abdominal pain or tenderness; 
  


• persistent vomiting; 
  


• lethargy or restlessness.
  

An increase in hematocrit and/or decreasing platelet count mark the recovery phase, where patients also show improved well-being, no fever, and better appetite. Recovery from infection provides lifelong immunity against that particular serotype. However, subsequent infections by other serotypes increase the risk of developing severe dengue.

Treatment includes paracetamol for fever and pain, adequate hydration, without for any anti-viral drugs or antibiotics, and requires close monitoring for any signs of bleeding.

Prevention people should observe include:

• wearing of  proper clothing in places endemic for mosquitoes 
  


• vaccines , which are still under investigation;
  


• use of mosquito repellant lotion; 
  


• elimination of mosquito breeding sites that include government-initiated programs such as  “Aksyon Barangay Kontra Dengue or ABaKaDa”
  

Medical Forum No. 252
Current Management of Devastating Traumatic Injuries of the Upper Extremity
Discussant: Nathaniel S. Orillaza Jr., M.D.

The upper extremity of the human body is designed for motion and provides the ability to manipulate the environment and hold tools.  The lower extremeties are used for standing, walking, jumping, running, kicking, and especially for bearing weight.

Musculoskeletal trauma is a relatively common injury, but has significant effects on patients’ lives.  This includes:

• Fracture: soft tissue injury complicated by a break in the bone;
  


• Soft tissue injuries, which are usually a combination of different layers or types:
  


• Skin: laceration, avulsion; n Muscle: strain, transection;
  


• Ligaments: sprain, transection, avulsion;
  


• Vascular: sharp / blunt, complete / incomplete;
  


• Neurologic: neuroplraxia / axonotmesis / neurotmesis, High / Low
  

Diagnosis evaluates:

• Age, Sex, Handedness, Occupation 
  


• Place of Injury (POI): environment
  


• Time of Injury (TOI): concept of “Golden period” dictates ideal timing of treatment
  


• Mechanism of Injury (MOI): anticipate degree of injury
  


• FOOSH (fall on out-stretched hand) 
  


• Crushing  
  


• Sharp (hacking, industrial)
  


• Gunshot n Motorcycle crash
  

Prevention of injuries require a lifestyle safety check and use of protective gears. Management of traumatic injuries include:

• Proper and timely evaluation, which is most important;
  


• Initial evaluation,  which looks at life versus limb, life threatening vascular injury in the acute stage; 
  


• Detailed evaluation, which looks at systemic or proximal to distal layers and neurologic and bone problems, which determines long-term outcome;
  

Treatment options are either non-surgical or surgical. The following factors should be considered.

• Surgery is not always needed but those who will, should be treated appropriately.
  


• Treatment plans should have realistic expectations. 
  


• Treatment should focus not on what the doctor can do but what the patient needs.
  


• Emergency setting should provide comfort and protection from further injuries.
  


• Setting expectations discusses restoring gross versus fine movements, rush versus taking time to recover.
  


• Gadgets and contraptions upgrade frequently, but basic principles are the same.
  


• Role of medical management and biologics.
  

Care after initial management considers that:

• any method of surgical or non-surgical intervention is only half the battle;
  


• rehabilitation modalities are just as important as the first part of treatment;
  


• amputation is an option of treatment only after all other treatments fail;
  


• choices include better prosthesis versus regeneration as well as more utilization of medical intervention.