Archive for June 2015

Egypt and Us

Last week I had the opportunity to visit Egypt and, among other things, take part in some medical clinics.  The medical care in Egypt is reasonably good in many areas, but not so much in the very poor section we served outside of Cairo.  Looking out of the window of the little bus as we rolled into town, it was hard not to notice garbage everywhere; it floated over the little canal that divided the road and littered the road itself.  In the end, it was part of the health challenge of this Egyptian town.

At the end of seeing a day’s worth of patients filing in, I was struck with the fact that there health challenges are similar in many ways to ours.  Like us, they suffer from arthritis, congestive heart failure, diabetes, headaches, hypertension, and bronchitis.

But there are some different challenges as well.  At least in these poorer towns, access to routine care for some of the more chronic problems is almost impossible.  So while we could identify high blood pressure, diabetes or heart disease, we could do little to effectively manage it with our one-time visit.

Another challenge these folks face that is not major for us is routine access to clean water and food.  Many of the children and adults had parasites sapping their energy and giving them various gastrointestinal complaints.  An anti-parasite medicine, albendazole, was one of my most frequently prescribed medicines; I can barely recall prescribing it while in the states.  And when I prescribed it in this little town in Egypt, I knew I was only temporarily reducing the worm burden in these patients.  Without a change in their water supply and food handling they would quickly be re-infected.

A couple of children were covered from head to toe with red bumps and blisters.  It took me a good while to realize this was not some infestation of mites but just severe chicken pox.  Here in the U.S. I rarely see chicken pox anymore and they are usually very mild cases.  Likewise Egypt still has some of the more serious vaccine-preventable diseases like polio.

So while the people were in many ways similar to those I see here in Tennessee: many delightful and a few a bit more cantankerous, some very sick from advanced congestive heart failure and others just needing reassurance that a small skin lesion wasn’t cancer, there were some clear differences in the overall systemic health challenges they face.

It left me with a heart for these folks and a thankfulness for the blessings we have in this country: ready access to clean food and water, a sanitation and waste system that works, availability of effective vaccines against many of the diseases that used to plague our children and adults, and access to routine health care to manage and minimize the complications of serious chronic diseases.

Our challenges are more of excess – excesses of food, entertainment, alcohol, and tobacco.  Choosing the healthier foods in reasonable portions, finding ways to bring regular physical exercise back into our crowded lives, not neglecting or mistrusting the available vaccines, and avoiding toxic habits – these are more the challenges of our world in the U.S.  They don’t account for every illness, but good choices in these areas drastically impacts the epidemics of chronic diseases in our country.  These are not meant as judgments, just observations to focus our efforts and count our blessings.


Kidney Stone Prevention

As I entered the exam room, Harry, one of the biggest toughest guys I have as a patient, was on his hands and knees rocking back and forth on the exam table and crying.  This guy is about 6’ 4 inches tall, weighs about 240 pounds and normally wears a huge smile beneath his mountain-man beard.  But a few hours earlier he had experienced sudden brutal left mid back pain.  The pain, with only slight fluctuation, had persisted until now.

Besides helping him get some pain relief, we ordered a type of CT scan that diagnosed a 4 mm stone in his left ureter, the tube that comes down from the left kidney into the bladder.  The good news is that most 4mm stones will pass on their own given adequate pain relief, lots of fluids, and perhaps a type of urinary medicine that increases the likelihood of passage.

In this case, he did indeed pass the stone within a few days without needing surgery or other procedures.  Needless to say, Harry was very interested in whether this was likely to happen again and whether there was anything he could do to prevent it.

Unfortunately, kidney stones are quite common, with 13% of men and 7% of women having at least one attack in their life-time.  Between a third and a half of patients who get one will eventually get another within five years.  If a repeat stone occurs, the chance of further stones becomes even higher.  Often when the CT scan is done, additional stones will be seen sitting painlessly up in the kidneys.  As long as they stay up there they rarely cause symptoms.  But, of course, they indicate a threat of moving down into the narrow ureters where they cause the intense pain of what we call a kidney stone attack.

Harry’s kidney stone was captured in a urine strainer and brought in so that we could send it off for analysis.  Like about 80% of kidney stones, it was a calcium-containing stone, primarily calcium oxalate. The remaining types of stones may be made up of crystals such as uric acid, the key component in gout, or struvite, often connected with urinary infections.

However, as it turns out, more detailed analysis of blood and urine chemistries has not been proven to reduce recurrences.  The good news is that there are some simple measures that are of some benefit.  Not surprisingly, one of these is very good hydration. Specifically, the goal is to drink enough fluids to produce at least two quarts of urine daily.  On a couple of occasions, a person would need to actually pick a day when they could urinate into a jug each time for 24 hours to see if they were achieving this goal.  Studies showed that these folks are able to decrease recurrent stones by 55% over 5 years.  Additionally, avoiding cola types of soft drinks reduced recurrence rates modestly.

If recurrences of kidney stone attacks are happening despite these simple measures, there are a couple of medicines that show a lot of benefit as well.  For example, thiazide diuretics (water pills) have been found to decrease recurrence by 50%, allopurinol by 35% and citrate by 75%.

Anyone who has had a serious kidney stone attack is usually very motivated toward not having another one.  The approach used to be rather complicated, but nowadays includes just a few things.  But these are things worth doing consistently if it allows you to avoid ever again having the kind of pain that makes a rugged man rock on an exam table in tears.