The Great Coffee Debate

Myths and Facts about coffee consumption.

Sierra Leone's 50th Independence Celebrations

How Salone was showcased in the Russian Federation.

Complications of Laparoscopic Surgery

Reasons for conversion to open surgery

Ambassador Yambasu arrives

Sierra Leone's New Ambassador to Russia arrives to assume office.

Atypical Clinical features of Appendicitis

An extract from an article at the the 5th International Conference on Surgery.

Thursday, November 7, 2013

ALL SURGEONS ARE PHYSICIANS, BUT NOT ALL PHYSICIANS ARE SURGEONS.

All doctors receive a similar education, whether they attend medical school and become an M.D., or an osteopathic college and become a D.O.. However, most will pursue specialized training in a specific field of medicine. Many of these areas of practice involve surgery, and their practitioners are referred to as surgeons. Those who perform little or no surgery are simply referred to as physicians. All surgeons are physicians, but not all physicians are surgeons.

Training
Medical education and training varies considerably across the world. Depending on jurisdiction and university, these may be either undergraduate-entry (most of Europe, India, China, Africa), or graduate-entry programs (mainly Australia, Canada, United States). In the US and much of North America, all doctors begin their careers in a three- to four-year undergraduate pre-medical program, earning a bachelor of science degree that satisfies the prerequisites for medical or osteopathic college. Those schools represent the next step, a four-year doctorate combining hands-on clinical experience with classroom instruction in physiology, pharmacology, organic chemistry, medical ethics and related topics. In some other parts of the world, initial training is taken at medical school which is traditionally divided between preclinical and clinical studies. The former consists of the basic sciences such as anatomy, physiology, biochemistry, pharmacology, pathology. The latter consists of teaching in the various areas of clinical medicine such as internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and surgery.  At graduation, the newly minted doctor must choose an accredited residency program in one or another area of practice. This is where career paths for physicians and surgeons diverge. Physicians spend their residencies practicing medicine under the supervision of experienced practitioners, while surgeons spend theirs learning a range of surgical techniques appropriate to their specialty.

What Physicians Do
Physicians may be specialists or practice primary care. Primary care physicians are generalists, such as family doctors, gynecologists and pediatricians. They build long-term relationships with their patients, counseling them on wellness and lifestyle choices, as well as treating their illnesses. Specialists focus on specific diseases, such as cancers or breathing disorders, or specific parts of the body, such as the digestive system or heart. They typically see patients for specific conditions, rather than providing general care. Both types of physicians treat illnesses, injuries and other conditions with medicines, physical therapy and other non-surgical techniques.

What Surgeons Do
Surgeons perform many of the same duties as other physicians, recording patients' medical histories and diagnosing illnesses, injuries and other conditions. However, while physicians' therapies typically encourage the body to heal itself, surgeons act directly to correct illnesses, injuries and deformities. Working through open incisions in the traditional way with scalpels or with tiny instruments inserted into the body through fine tubes, surgeons cut, fuse and reshape the body's tissues to restore proper function. Some physicians who are classed as non-surgeons -- including interventional cardiologists, neurologists and radiologists -- use the same minimally invasive techniques to perform repairs on their patients.

Comparative Income(US data)
In its 2011 salary survey, medical staffing firm Merritt Hawkins reported a salary range of $130,000 to $290,000 per year for family medicine, with an average salary of $178,000. For emergency medicine physicians, the average was $255,000, with the high and low ranging from $160,000 to $380,000 per year. Anesthesiologists fared better, with a range of $290,000 to $475,000 and an average salary of $355,000 a year. General surgeons reported an average salary of $330,000, with a low of $205,000 and a high of $450,000. Orthopedic surgeons had especially high salaries, ranging from a low of $380,000 per year to a high of $650,000. Their average salary was $532,000 per year.

 Most of the info, with some alterations, from http://forum.facmedicine.com/

Monday, April 15, 2013

ATYPICAL CLINICAL FEATURES OF APPENDICITIS



5th International conference “Surgery 4 All”. Moscow. Published in the “SURGERY made simple” Magazine
ATYPICAL CLINICAL FEATURES OF APPENDICITIS
Presented by: I.M. Kapuwa; M.A. Chinikov , MD, PhD




Extract...

Appendicitis is an inflammation of the appendix that causes the organ to fill with fluid. In classic descriptions of appendicitis, patients will experience a progressively worsening amount of periumbilical (near the navel) pain in the abdominal region followed by nausea, right lower quadrant pain, and later, vomiting with fever. However, some people, especially pregnant women, the elderly, children and people with situs inversus totalis (mirrored positions of internal organs), may suffer from atypical symptoms, making a proper diagnosis more difficult.
Acute appendicitis is one of the most common surgical emergencies encountered by general surgeons. When appendicitis manifests in its classic form, it is easily diagnosed and treated. Unfortunately, these classic symptoms occur in just over half of patients with acute appendicitis therefore, an accurate and timely diagnosis of atypical appendicitis remains clinically challenging and is one of the most commonly missed problems in the emergency department. Furthermore, the consequence of missing appendicitis, leading to perforation, significantly increases morbidity and prolongs hospitalization.


WHAT YOU NEED TO KNOW: Anatomy - 
Normal Appendix anatomy
Blind pouch off of cecum
Contains lymphoid tissue which peaks in adolescence, atrophies with age
Function still unclear
Appendix can be anywhere within peritoneal cavity
One study showed 65 % retrocecal, 31 % pelvic


APPENDICITIS INCIDENCE & COMPLICATIONS
o 6 % lifetime incidence, Slightly more common in men
o 69 % are ages 10 to 30
o 1 in 6 of the population will have an appendectomy.
o More common in European societies (Diet); less common in vegetarians
o Only 55% have classical features.
o Atypical 45%
o Up to 30 % misdiagnosed initially
o Mortality : 0.1 to 0.2 % unruptured, 3 to 5 % ruptured Significant morbidity


Various positions of the Appendix
PRESENTATION: Atypical presentation of appendicitis may occur because of the position of the appendix, the age of the patient, or coexisting conditions such as pregnancy. In such cases the diagnosis may be particularly challenging. The position of the appendix as related to the caecum may also influence the clinical presentation and the differential diagnosis. When the inflamed appendix is in retroacecal and retroileal position it is shielded from the anterior abdominal wall by the overlying caecum and ileum. The pain, therefore, seems less severe with a mild to moderate manifestation that doesn't worsen or shift.
The classic shift of pain from the epigastrium to the right lower quadrant may not occur. Tenderness or sensitivity to touch will be slight and not worsen. In some cases, there is no tenderness at all. Another atypical symptom of appendicitis is a change in bowel movements, including a reduction in frequency or a change in the consistency, with harder and drier stools. Without the presence of pain and tenderness, appendicitis is likely to be misdiagnosed as constipation.
Urinary frequency may result from direct irritation of the ureter. Muscular rigidity is absent and abdominal tenderness is minimal in these cases. With inflamed appendix in pelvic position, pain is often localized to the lower abdomen. The absence of abdominal signs can be deceiving, but tenderness is usually elicited on rectal examination.

DIAGNOSIS:  Diagnosis is clinical; for there is no specific test to confirm the diagnosis of acute appendicitis. The Alvarado score can be used in the diagnosis of appendicitis. The score has 6 clinical items and 2 laboratory measurements with a total of 10 points.

THE ALVARADO CLINICAL  ‘MANTRELS’ SCORE.                                                               Established in 1986
Characteristic
Point
Migration of pain to right lower quadrant (RLQ)
1
Anorexia
1
Nausea / vomiting
1
Tenderness in RLQ
2
Rebound pain
1
Elevated temperature
1
Leukocytosis
2
Shift of white blood cell count to left
1
Total
10
Diagnosis of appendicitis in the elderly is often delayed. Even with advanced inflammation, pain may be minimal and fever is absent. Appendicitis in pregnancy is also difficult to diagnose. Patients usually seek obstetric advice for their symptoms.  Area of maximal abdominal tenderness may be adjacent to the umbilicus or in the right subcostal area because of upward displacement of caecum. 

Imaging diagnostics:
Ultrasonography
Computed tomography/ magnetic resonance imaging
X-ray 
Laparoscopy 

Vaginal/rectal examination