A piece of my day, nephrosis

I pushed the door open
I don’t remember knocking, nervous
He was standing at the door
A very important person or VIP, as they called them
His wife was sitting by the chair next to the computer

“How are you sir ?” I said stretching my hand for a hand shake

I saw the puzzle in their eyes
Aren’t we VIP, of all doctors why you ?
I could read their minds

Yes, I am from Africa
Yes, I went to medical school in Africa
Yes, I have seen patients with protein in their urine before
Yes, I have treated patients like you before
No, I am not related to the King of Ethiopia

And then,

After the leg swelling is gone
After the protein in the urine is gone
After the kidney function has recovered
After the nephrosis is cured

When I walked in
She was reading a novel
He had a newspaper’s sport page open

“Doc, what was my last urine protein measurement ?” he asked.

“You are in remission, Sir.”

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A piece of my day, renal rounds

Detroit, Michigan,2008

Attention Doctors, Nurses, Specialists, Visitors,
We ask you please,
Do not talk negative things in front of her or close to her;
Smile to her, be kind and positive;
Be compassionate, please!

I looked at those words on a white piece of paper posted at the door of the hospital bed where she had been admitted for over 2 weeks with failure of her lungs, liver and kidneys. I was called because her kidneys had shut down.

‘Who are you?’
‘Which service?’

Before I said a word her son pulled himself up close and looked at my name tag.

‘I can’t deal with that one,’ he said pointing at my long last name.

Her BP was so low that she was requiring medications to maintain it. She couldn’t breath on her own so had to be on a mechanical ventilator. I looked at the flow sheet first. All the 24 hour activities were neatly jotted down. The first page had her name, age, daily weight followed by her infusions, vital signs starting with blood pressure and followed by her pulse and temperature in degree Celsius. I focused on her urine output. She had had 325 cc of urine the previous 24 hours but the last few hours it had decreased to a bare 5 cc per hour. Then I looked at the flow sheet for the continuous slow dialysis which was initiated 2 days prior by another kidney specialist who was covering the weekend.

I washed my hands quickly and focused on her again starting with a physical exam. The melody that was coming from the African classic music in the room was heard over the squeaking of the mechanical ventilator and the dialysis machine. The wall inside the room was decorated by her pictures, some with her husband and her children; a smiling beautiful mother in her primes. Some of them may have been taken when she was young and still lived in Africa. Her husband was pacing the room. He would walk out and come back in holding his bible. He would stare at her for minutes continuously. He didn’t ask any questions. He knew what was left was beyond us. I left the room with the tranquility and peace hoping His miracles.

When I went back the next day to see her she had made some progress. She was able to support her own blood pressure; her kidneys had started to wake up, so to say; and she was making effort to breathe on her own. As I left the room, her husband showed up. Ignoring me, he continued pacing the room with his hands folded across his chest.
I updated him about her improvement. His face lighted up for a moment but almost instantly continued mumbling words I couldn’t comprehend.

She continued to improve over the next several days. She started breathing without the mechanical ventilator. Her kidneys fully recovered and she was taken off dialysis.

Thank God, she finally walked home with her family after an ordeal that lasted a little more than a month but the words her son posted in her room reverberate in me even today when I walk to any patient’s room.

Do not talk negative things in front of her or close to her;
Smile to her, be kind and positive;
Be compassionate, please!

What a caring family. What a lesson!

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An encounter in Milano Centrale

I arrived at Milan Central Train station at around 11 am. It was a beautiful Sunday morning. Milano Centrale is one of the oldest and grandest train stations in Europe. It was also my first trip to Italy. Just about the only thing I remember reading about The Milan Central Station is the story of Luigi Goj with his battalion leaving Milan for Massawa/Eritrea, his parents waving good bye from the platform, to what would be their eventual defeat in the battle of Adwa in 1896 (The Battle of Adwa: African Victory in the Age of Empire by Raymond Jonas).

Moments after the train stopped at platform 6, the passengers departed one by one. I was one of the first.

The ride itself was enjoyable. It took us only four hours to get to Milan from Basel, Switzerland where I spend the night in a friend’s one bed room apartment after I arrived late Saturday night from Cologne. The world cup fever was high in Europe. I catched part of the Brazil-Chile game at the train station in Cologne. My arrival in Basel four hours later was greeted by a delicious meal of Ravioli and a glass of red wine. A soccer fan, my friend was visibly happy that Brazil edged out Chile on penalties. We had a dish of scrambled ingera (Ethiopian bread) and roasted dried meat (quanta fir fir) for breakfast. A rush to get on time to catch the train ended up giving me enough time for a cappuccino at the Basel SBB, then off to Milan mesmerized by the unending beauty of southern Switzerland.

Milano Centrale was busy with people from all over the world, so it felt. My plan was to meet my long lost aunt that I never saw in over sixteen years. Like every immigrant’s story, ours is a family spread across many continents. She was supposed to meet me at the platforms but was nowhere to be seen. I was lost in the crowd looking for my aunt but enjoying along the way the magnificent architectures of the train station when I saw a familiar face walking towards me. We exchanged greetings as if we were brothers. He had a new mobile phone in his hand and was trying to figure out how to use it. Marks on his face gave away his northern Ethiopian or Eritrean roots. His accent would soon confirm it. One can tell from his looks that he was brand new to a foreign land. I didn’t ask him where he was going or coming from. I fidgeted on his phone and gave it back to him. The instructions were all in Italian and I had long forgotten the few words grandpa thought me when I was very young. In a broken Amharic he asked me if I knew where the toilet was located. After a few hundred steps away I saw the sign and headed there only to find out that one has to pay 1 Euro to use it.
He shrugged.

“Let’s go” he said, walking faster to the central area.

You don’t want to use the toilet?

“I will wait.”

Why?

“That is over 20 at home,” he said.

He was new to Italy having just arrived, like so many East African brothers and sisters, leaving behind family and friends in the desert or the sea, for a better shot at life. It took 12 days for Luigi Goj and other Italian troops to get to Massawa from the very platforms we stood on but the consequence of their actions is still felt,one way or another, in the poverty and instability of East Africa leading many to a life of misery and constant search for survival under extreme conditions.

Soon he met many others and disappeared in the city of Milan to search for a living. I left to Bologna with my aunt to have some time to tell our stories.

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Ebola virus disease

( reposted with some updates)

The Ebola virus was first identified in Western Equatoria State of South Sudan and in a nearby region of Zaire (now the Democratic Republic of the Congo) in 1976 after significant epidemics in Yambuku, northern Zaire, and Nzara, Southern Sudan. Ebola Virus Disease, formerly known as Ebola Hemorrhagic Fever (EHF) is one of the most virulent diseases known to humankind. It causes death in 50-90% of all clinically ill cases. The disease is caused by infection with the Ebola virus, named after a river in the Democratic Republic of the Congo (Ebola River). Reports indicate that current outbreak has a fatality rate of 50-70%.

How Ebola Outbreaks Start

First human cases start with infection by an animal-Chimpanzees, gorillas, monkeys, forest antelopes, fruit bats, porcupines… However the origin of the current outbreak is unknown.

Infection from person-to-person creates an outbreak

-Direct or indirect physical contact with body fluids of infected person (blood, saliva, vomitus, urine, stool, semen)

Well known locations where transmission occurs

– Hospital: Healthcare workers, other patients, unsafe injection practices, poor management of infectious waste

-Communities: Family, friends and contacts caring for patients Funeral practices including body handling, communal hand washing

Ebola transmission

  • Direct contact with wounds, body fluids like blood, saliva, vomitus, stool and urine of a person suffering from Ebola or splashing of such fluids from an infected person into another person’s eyes
  • Direct physical handling of dead bodies of persons who have died of Ebola
  • Handling dead animals especially monkeys
  • Infection can also occur if broken skin or mucous membranes of a healthy person come into contact an Ebola patient’s infectious fluids such as soiled clothing, bed linen, or used needles.
  • Health workers frequently get exposed to the virus when caring for Ebola patients, when they do not wear personal protection equipment, such as gloves, masks when caring for the patients.

The incubation period of Ebola

The time interval from infection to onset of symptoms is 2 to 21 days.

During this time, the patient becomes contagious once they begin to show symptoms.

They are not contagious during the incubation period

Clinical Symptoms of Ebola

Initial Phase:

  • Sudden onset of fever
  • Intense weakness
  • Muscle pain
  • Headache and sore throat

Second phase

  • Vomiting, diarrhea and skin rash
  • Impaired kidney and liver function, and
  • In some cases both internal and external bleeding

Severe Cases:

  • Bleeding under skin and internal organs

Laboratory diagnosis

At the initial stages of the infection clinical diagnosis may be difficult because the early symptoms like fever, vomiting and diarrhea are often seen in other diseases that occur more frequently.

Ebola virus infections can only be confirmed through advance laboratory testing.

Testing is conducted in selected laboratories with maximum biological containment standards because

Ebola samples are an extreme biohazard risk.

Ebola treatment / supportive therapy

There is currently no specific treatment to cure the disease, however, new drug therapies ( eg. Zmap) are under evaluation and trial. Brincidofovir was recently approved by FDA. Blood transfusion from Ebola survivors have also been used in few patients.

Severely ill patients require intensive supportive care which includes intravenous fluids or oral rehydration with solutions that contain electrolytes because they are frequently dehydrated.

Some patients will recover with the appropriate medical care.

To prevent further spread of the virus, people that are suspected to have the disease should be isolated from other patients and treated by health workers using strict infection control precautions

 Prevention and Control

  • Currently there is no licensed vaccine for Ebola virus disease, several vaccines are being tested but none is available for clinical use.
  • Avoid direct contact with body fluids, blood, saliva, vomitus, urine, and stool by wearing protective materials like gloves and goggles.
  • Do not touch wounds of an infected person with unprotected hands.
  • Do not use skin piercing instruments that have been used on a patient suffering from Ebola.
  • After handling a patient suffering from Ebola, you must wash your hand thoroughly with soap and water.
  • Animal products (blood and meat) should be thoroughly cooked before consumption.
  • Avoid handling sick or dead animals such as non-human primates and other forest animals like fruit bats and porcupines.
  • Persons who have died of Ebola must be handled by trained health staff wearing strong protective wear and buried immediately to prevent spread of the disease.
  • Avoid feasting and funeral gatherings during Ebola outbreaks.
  • Raising awareness of the risk factors and measures people can take to protect themselves are the only ways to reduce illness and deaths.

Educational public health messages for risk reduction should focus on:

  • Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes, and the consumption of their raw meat
  • Handle animals with gloves and other appropriate protective clothing
  • All animal products (blood and meat) should be thoroughly cooked before consumption
  • Avoid any contact with Ebola patients
  • Gloves and personal protective gear should be worn when taking care of patients at home
  • Regular hand washing should be practiced at all times, and should be strictly done when taking care of patients
  • Burial of people who have died of Ebola should be conducted as soon as possible, under supervision of trained health personnel

Essential components of control

  • National leadership
  • Strong community awareness and support
  • Immediate care of affected patients
  • Strengthen the capacity of the local health system

Stop transmission:

  • Actively identify, investigate ALL new cases, contacts, deaths
  • Maintain detailed databases
  • Monitor contacts for 21 days (isolate if ill)
  • Confirm absence of virus by testing during recovery

Prevent

  • Informed healthcare workers, consistent infection control /prevention
  • Culturally-sensitive practices to reduce transmission

 

 Dr Mamude Dinkiye is a pediatrician. He completed medical school at Jimma Univerisity and a speciality training in Pediatrics from the School of Medicine at  Addis Ababa University. He also holds a Mater of Public Health degree from the School of Public Health at Hawassa University. He currently practices and lives in South Sudan.

 

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Nodding Syndrome

Nodding disease or nodding syndrome is an unusual syndrome of unknown etiology characterized by nodding with or without meals and associated with generalized myoclonic type seizures, severe mental retardation, and physical growth impairment. It is affecting children mainly between 5 … Continue reading

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Ebola Virus Disease

 

Mamude Dinkiye, M.D., MPH

Juba, South Sudan

The Ebola virus was first identified in Western Equatoria State of South Sudan and in a nearby region of Zaire (now the Democratic Republic of the Congo) in 1976 after significant epidemics in Yambuku, northern Zaire, and Nzara, Southern Sudan. Ebola Virus Disease, formerly known as Ebola Hemorrhagic Fever (EHF) is one of the most virulent diseases known to humankind. It causes death in 50-90% of all clinically ill cases. The disease is caused by infection with the Ebola virus, named after a river in the Democratic Republic of the Congo (Ebola River).

There are 5 distinct sub-types of Ebola virus:

  • Ebola Zaire——————DRC (Democratic Republic of Congo)
  • Ebola Sudan—————-South Sudan
  • Ebola Cote D’Ivore——-Cote D’Ivore
  • Ebola-Bundibugyo——-Uganda
  • Ebola Reston————– USA   (Primates only)

How Ebola Outbreaks Start

First human cases start with infection by an animal-Chimpanzees, gorillas, monkeys, forest antelopes, fruit bats, porcupines… However the origin of the current outbreak is unknown.

Infection from person-to-person creates an outbreak

-Direct or indirect physical contact with body fluids of infected person (blood, saliva, vomitus, urine, stool, semen)

Well known locations where transmission occurs

– Hospital: Healthcare workers, other patients, unsafe injection practices, poor management of infectious waste

-Communities: Family, friends and contacts caring for patients Funeral practices including body handling, communal hand washing

Ebola transmission

  • Direct contact with wounds, body fluids like blood, saliva, vomitus, stool and urine of a person suffering from Ebola or splashing of such fluids from an infected person into another person’s eyes
  • Direct physical handling of dead bodies of persons who have died of Ebola
  • Handling dead animals especially monkeys
  • Infection can also occur if broken skin or mucous membranes of a healthy person come into contact an Ebola patient’s infectious fluids such as soiled clothing, bed linen, or used needles.
  • Health workers frequently get exposed to the virus when caring for Ebola patients, when they do not wear personal protection equipment, such as gloves, masks when caring for the patients.

The incubation period of Ebola

The time interval from infection to onset of symptoms is 2 to 21 days.

During this time, the patient becomes contagious once they begin to show symptoms.

They are not contagious during the incubation period

Transmission can still occur 7 weeks after recovery e.g. through semen

Clinical Symptoms of Ebola

Initial Phase:

  • Sudden onset of fever
  • Intense weakness
  • Muscle pain
  • Headache and sore throat

Second phase

  • Vomiting, diarrhea and skin rash
  • Impaired kidney and liver function, and
  • In some cases both internal and external bleeding

Severe Cases:

  • Bleeding under skin and internal organs

Laboratory diagnosis

At the initial stages of the infection clinical diagnosis may be difficult because the early symptoms like fever, vomiting and diarrhea are often seen in other diseases that occur more frequently.

Ebola virus infections can only be confirmed through advance laboratory testing.

Testing is conducted in selected laboratories with maximum biological containment standards because

Ebola samples are an extreme biohazard risk.

Ebola treatment / supportive therapy

There is currently no specific treatment to cure the disease, however, new drug therapies ( eg. Zmap) are under evaluation and trial.

Severely ill patients require intensive supportive care which includes intravenous fluids or oral rehydration with solutions that contain electrolytes because they are frequently dehydrated.

Some patients will recover with the appropriate medical care.

To prevent further spread of the virus, people that are suspected to have the disease should be isolated from other patients and treated by health workers using strict infection control precautions

 

Prevention and Control

  • Currently there is no licensed vaccine for Ebola virus disease, several vaccines are being tested but none is available for clinical use.
  • Avoid direct contact with body fluids, blood, saliva, vomitus, urine, and stool by wearing protective materials like gloves and goggles.
  • Do not touch wounds of an infected person with unprotected hands.
  • Do not use skin piercing instruments that have been used on a patient suffering from Ebola.
  • After handling a patient suffering from Ebola, you must wash your hand thoroughly with soap and water.
  • Animal products (blood and meat) should be thoroughly cooked before consumption.
  • Avoid handling sick or dead animals especially monkeys, other non-human primates and other forest animals like fruit bats and porcupines.
  • Persons who have died of Ebola must be handled by trained health staff wearing strong protective wear and buried immediately to prevent spread of the disease.
  • Avoid feasting and funeral gatherings during Ebola outbreaks.
  • Raising awareness of the risk factors and measures people can take to protect themselves are the only ways to reduce illness and deaths.

Educational public health messages for risk reduction should focus on:

  • Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes, and the consumption of their raw meat
  • Handle animals with gloves and other appropriate protective clothing
  • All animal products (blood and meat) should be thoroughly cooked before consumption
  • Avoid any contact with Ebola patients
  • Gloves and personal protective gear should be worn when taking care of patients at home
  • Regular hand washing should be practiced at all times, and should be strictly done when taking care of patients
  • Burial of people who have died of Ebola should be conducted as soon as possible, under supervision of trained health personnel

Essential components of control

  • National leadership
  • Strong community awareness and support
  • Immediate care of affected patients
  • Strengthen the capacity of the local health system

Stop transmission:

  • Actively identify, investigate ALL new cases, contacts, deaths
  • Maintain detailed databases
  • Monitor contacts for 21 days (isolate if ill)
  • Confirm absence of virus by testing during recovery

Prevent

  • Informed healthcare workers, consistent infection control /prevention
  • Culturally-sensitive practices to reduce transmission

 

 Dr Mamude Dinkiye is a pediatrician. He completed medical school at Jimma Univerisity and a speciality training in Pediatrics from the School of Medicine at  Addis Ababa University. He also holds a Mater of Public Health degree from the School of Public Health at Hawassa University. He currently practices and lives in South Sudan.

 

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A piece of my day…unpleasant surprise

Here comes the much awaited summer after the coldest winter in decades. It didn’t warm up in earnest until June. New medical students, residents and fellows were eagerly waiting for the start of patient rounds. Hospital assignments in July need especial attention until the interns and residents settle in. Some had travelled across oceans and were completely new to the culture. Others had just left their loved one for the first time and home sick in a new city.
The anxiety of rounding with attending physicians makes everyone nervous about a trivial medical question that can be thrown at you that can take you off guard. So when the attending physician walked in at 9 am everyone was ready to round having made final touches to either vital signs or physical exam findings or assessment and plans about their patients.
The introduction was brief: a medical student from Kansas, an intern from Detroit, a resident from Peru, a visiting scholar from Egypt; a melting pot, like what America is any way.

The attending physician briefly described expectations for the month. The hospital’s teaching rotations are on monthly basis. Trainees get feedbacks and evaluations at the end of each month. Shortly after that they pulled chairs and sat for brief chart rounds before actually going to the patients’ rooms.

It wasn’t long before everyone started to feel unease, some even uncomfortable. The questions were appropriate to the level of training and they picked them up one by one with correct answers. What a smart group it was. They were not interrupted by pages from the nurses either. The attending physician was also nervous.

There was a strong and non –verbal signal, foot odour!

The human scent is genetically controlled but there are several factors that can influence it such as dietary and medicinal intake and use of fragrance products. When there is over secretion of sweat or what is termed as hyper-hyperhidrosis, the excessive water leads to bacterial overgrowth creating malodor which can create embarrassment and diminishes self-confident. Some individuals may not smell that particular odor (anosmia) and may not recognize it until alerted. Sweat on the other hand is very important to regulate body temperature enabling us to live in different climates. Sweat gland secretions are odorless but also secrete malodor precursors such as proteins, lipids, volatile short-chain fatty acids which when metabolized by bacterial can give rise to malodour. Emotional stimuli can also lead to sweat secretions particularly from palms and soles where there is high concentration of sweat glands. Foot odour is mainly due to short chain fatty acids. Isovaleric acid is a common foot odourant. It is catabolized from glycerol and lactic acid by bacterias which are part of the normal skin flora such as Propionibacteria, Staphylococcus, and Corynebacteria. Bacterial prefer humid environment. Topical anti-perspirants to diminish sweat which often contain metallic salts are often first lines of treatment. Local every day remedies such as baking soda or anti-microbial agents and odour absorbers can also be employed as treatment.

The round continued in to bedsides. The odour got worse as the day went by. Most managed distracted by the teaching and the work load ahead of them.

No one was sure where it was coming from until of course he left…

That physician was me.

Reference
Int J Cosmet Sci. 2011 Aug;33(4):298-311.

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