22 January 2007

1. Growing Skull Fracture
2. White Goop
3. What's the Diagnosis?
4. Anal Fissure
5. Undescended Testes. Stopping Bottle
6. Heritability of Depression
7. Colic
8. Varicocoele
9. Disclaimer

• Read Questions & Answers in Another Column

Growing Skull Fracture

-(unsigned)

Dear ?: I wish you had signed your e-mail including your professional degree or affiliation in order to provide a little more information about yourself. From your comments on skull fractures you sound like a healthcare professional. Since I have answered so many questions over the years, I cannot remember the letter you referred to but certainly appreciate your suggestions for additional information which would be of benefit to my readers.

Sincerely,
Dr. Warren

Sincerely,
-Sarah

Dear Sarah: You need to see an ophthalmologist to find out what is causing your problem. A few years is more than enough time to live with an annoying symptom. Now it's time to see a doctor. Without examining you and the white goop it is not possible for me to tell if you have an infection (conjunctivitis, pink eye), an allergy, or a blocked tear duct.

Sincerely,
Dr. Warren

age--13 yrs

wt--30 kg

symptoms----- fever high grade almost through out the day, rash all over resembling urticarial rash ,rash is pruritic, oedema eyes palms and feet, no evidence of free fluid anywhere else, mild cough, throat mildly congested, chest clear.
no other signs or positive history

investigation done ---- haemogram ----- hb--- 12.3 gm%, tlc --- 21800/cmm, esr --13 mm

serum electrolyte ---normal values

blood urea & creatinine ------- normal values

serum protines & LFT ---awaited

Thank you.

with regards,
-SPNH

Dear SPNH: It is not possible for me to provide diagnoses by e-mail based on scant laboratory data and physical findings. Naturally, when you mention edema, I am interested in the urine protein since a child may be nephrotic with chemically normal kidney function, but your description of an urticarial rash with cough and fever is most consistent with a severe allergic reaction, perhaps a serum sickness. The problem for the physicians ministering to this child is to determine if the allergic component is in response to an infectious agent which is causing the fever, or if the entire problem is allergic or rheumatic (JRA and lupus can cause fever and rashes).

Sincerely,
Dr. Warren

I would like you to advise me on what my next step should be.

I had my first baby boy on the 28th of December 1999, the birth was natural, not much problem - no drugs just entonox. For about 3 months after the birth my sore hint end was being treated as for piles. I had bleeding ++ when I went to the toilet and a sore rear end, constantly,(a throbbing pain) but was excruciating when I passed any waste. I was prescribed Fybogel - a bulking agent ( as you can imagine this didn't help much) and proctofoam for piles. I saw 3 different GPs who each did not examine me, just said it was piles after childbirth. I had problems with piles before I was even pregnant.

I then, after listening to my sister and brother-in-law, who are both GPs, decided to go back to see another doctor. This doc did examine me and said I had an anal fissure. He prescribed 0.2% GTN ointment and Lactulose. I was to apply the GTN externally 2 times a day and wait an hour and a half before breast feeding. And take 2 x 15mls per day of lactulose. I then read some of the emails on your site and found out that the ointment should be inserted inside the anal canal. So I called the doc, who was quite vague, but then said okay insert it. I was also advised to increase the lactulose to 3 x 15mls a day as it didn't seem to be making much difference.

I tried warm baths, Aloe Vera gel and hammamelis, Lidocaine creams etc etc.. Now my son is 6 months old - I have been treating the fissure for approx. 3 months and it is improving slowly. I am getting less blood when I go to the loo and the pain is not so intense but it is still there. Some days are pain free, then I go to the loo and it starts the pain up again.

I was at the doctors 2 weeks ago and he suggested I go to the surgeon who will inject the fissure with botulism toxin.

I got the appointment through for the beginning of August. I hope and pray that it is away by this, as I would dread going under general anaesthetic. I am unsure whether or not I want the surgery or if I should keep going with the GTN. - maybe increase the amount of applications per day?? Or just give it a bit more time!!! I don't get headaches with the cream!

Maybe once I stop breastfeeding and get a bit more sleep it may heal?!? Please advise/help me.

Yours A Desperate AF Sufferer
-PM

Dear PM: Hemorrhoids (piles) may cause pain if they are thrombosed or if they are left sticking out the anus after a BM and become strangulated, but as a general rule, they don't cause severe pain on defecation. That is more common with an anal fissure. A fissure is a tear in the anal skin, most often caused by passing a hard stool. One thing I learned in researching the answer to your question is that a chronic anal fissure is maintained by contraction of the internal anal sphincter. Once a fissure has formed, any bowel movement can aggravate it, but hard stools are more likely to cause a problem. Therefore, the treatment is aimed at keeping the stool soft and moist enough to pass through the anus without reopening a healing fissure. This is the purpose of bulking agents such as the Fybogel you mentioned and lactulose. Anti-inflammatory preparations such as proctofoam, or suppositories or ointments containing an anti-inflammatory steroid are used to relieve the inflammation. Dietary changes to keep the stool soft are also helpful. So might taking a lubricant like mineral oil be helpful.

Injections of botulinum toxin and application of topical nitroglycerin ointment for the treatment of chronic anal fissure is aimed at decreasing or eliminating the maintained contraction of the internal anal sphincter which causes the chronic anal fissure. According to an article, A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. by G. Brisinda, et al, in the New England Journal of Medicine - 1999 Jul 8; 341(2): 65-9, "Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective nonsurgical treatment."

Sphincterotomy, which is the surgical treatment of choice, is successful in 85% to 95% of patients, but permanently weakens the sphincter and therefore might be associated with anal deformity and incontinence.

According to an article, Botulinum toxin injections in the internal anal sphincter for the treatment of chronic anal fissure: long-term results after two different dosage regimens. by G. Maria, et al, in the Annals of Surgery, 1998 Nov; 228(5): 664-9, "Botulinum toxin is safe and effective in the treatment of anal fissure. It is less expensive and easier to perform than surgical treatment. No adverse effects resulted from injections of the toxin. The higher dosage is effective in producing long-term healing without complications."

One other article that might interest you discusses the treatment of internal hemorrhoids which contributed to chronic anal fissure. The article, Resolution of chronic anal fissures after treatment of contiguous internal hemorrhoids with direct current probe. by GA Machicado, in Gastrointestinal Endoscopy, 1997 Feb; 45(2): 157-62, found that "DC probe treatment for chronic anal fissures associated with internal hemorrhoidal disease is an important advance as an effective, safe, and cost-effective nonsurgical treatment in selected patients."

I hope you find this information useful. I certainly know a lot more about the treatment of anal fissures than I did before I tried to answer your question.

Sincerely,
Dr. Warren

When should I take him off the bottle?

-Cheri

Dear Cheri: By 1 year of age, if your son has an undescended testicle, he should be evaluated by a pediatric urologist. Years ago physicians used to wait longer but that was changed because it was found that waiting to bring down the undescended testis may risk damaging it.

Most children should come off bottles between 1 and 2 years of age, but it depends on how well the child drinks from a cup and how attached he is to his bottle. If a child is very dependent on his bottle, before stopping his bottles his use of the bottle should be restricted by decreasing the number of bottles given and insisting that the bottle be drunk in the high chair and be put away rather than allowing the child to walk around with it and use it whenever he is cranky.

Sincerely,
Dr. Warren

Sincerely,
-Jason

Dear Jason: The contribution of genetics vs. environment regarding depression is a complex one. Certainly, growing up in a household with a depressed parent, or having survived the suicide of a parent can be tough on the psyche even without a genetic predisposition. Studies suggest that there is definitely a genetic contribution.

According to the article by Alan M. Gruenberg and Reed D. Goldstein in Tasman: Psychiatry, 1st ed., Copyright © 1997 W. B. Saunders Company,

Familiarity with risk factors for depression may help the psychiatrist recognize or diagnose this common and serious psychiatric illness. Accordingly, the Depression Guideline Panel enumerated 10 primary risk factors for depression: 1) history of prior episodes of depression; 2) family history of depressive disorder, especially in first-degree relatives; 3) history of suicide attempts; 4) female sex; 5) age at onset before 40 years; 6) postpartum status; 7) comorbid medical illness; 8) absence of social support; 9) negative, stressful life events; and 10) active alcohol or substance abuse.

They go on to say,

Unipolar or nonbipolar MDD [major depressive disorder] has been demonstrated to cluster in the first-degree relatives of patients with depression. The observation that MDD is familial, however, does not address whether the familial aggregation may be due to nongenetic or familial environmental factors. Multiple risk factors for MDD have been reported, including gender, early parental loss, parental separation, rearing patterns, trauma and abuse, personality factors, prior major depression, low social class, and stressful recent life events. Although familial aggregation could be due to genes alone, environmental risk factors seem important.

Twin studies provide methods for separating genetic and environmental contributions to the aggravation of depressive disorders in families. Several twin studies of major depression ascertained in clinical settings have reported higher concordance rates in monozygotic [identical twins] than in dizygotic [fraternal] twins, consistent with evidence of genetic liability to depression. A community-based twin study of major depression has confirmed the role of genetic factors in liability to adult depressive symptoms.

Kendler and colleagues estimated that the heritability of liability to depression in women, depending on the criteria used in diagnosing MDD, was 33% to 45%. Moreover, a moderate role for individual specific environmental experiences was demonstrated in influencing the risk for depression. A subsequent report on the prediction of major depression in women demonstrated an important etiological role for the combination of genetic factors and specific individual environmental experiences in influencing vulnerability to depression. Given the estimated heritability in MDD of approximately 50%, converging evidence supports the important role of environmental experiences in the etiology of major depression.

For more information on this subject check some of the links at the following web site: http://www.psycom.net/depression.central.genetics.html

Sincerely,
Dr. Warren

-SV

Dear SV: Unfortunately, colic is one of those difficult aspects of infancy which nobody has any guaranteed solutions to. Since formula sensitivity may cause babies to be colicky switching to a hypoallergenic formula such as Nutramigen is an excellent idea. If it's going to help it could take a week or two. Gas is often blamed for colic and is the reason many parents resort to Mylicon drops.

The time honored approach to dealing with colicky infants is to walk the floors with them. Many of these infants are easily overstimulated, so care must be taken not to rock them too vigorously in our efforts to calm them. I highly recommend gently rocking in a rocking chair in a room with subdued lighting. The human voice can be very soothing to an infant, so talking about anything or singing can help. The feeling of Mom's heartbeat may also help since the baby spent 9 months hearing the whoosh of blood flowing through Mom's aorta. There used to be some devices on the market which rocked the crib and simulated the motion of a car, but those seem to have disappeared. Still, there's sometimes nothing like getting into the car for a ride to calm a screaming infant.

If a baby screams for hours without a break, a medical evaluation is warranted to be sure that there isn't any serious reason for the screaming. Even if it isn't that extreme, if the screaming goes on for hours every day the baby should be evaluated to be sure there isn't some medically treatable cause for his miseries.

Perhaps the most important aspect of dealing with colic is respite for the harried Mom. Being a mother may be both the most important as well as rewarding thing you ever do, but sometimes you just need a break. Whether you enlist the help of friends or relatives, or hire a baby-sitter, you need to have some time just for yourself away from the stress of caring for your baby. This break will leave you more relaxed making it easier for you to calm your baby. Overwhelmed moms sometimes unwittingly transfer their tension to their infants making the crying worse.

Sincerely,
Dr. Warren

Thanks.

-Ian

Dear Ian: I cannot quote you any statistics regarding the frequency of low sperm counts and infertility with varicocoeles; however, I can tell you that the approach to managing varicocoeles has changed. The days of doing nothing until a man discovers his wife isn't getting pregnant are past. A man who has a varicocoele should have surgery if the varicocoele is large, causing pain, or if the testicle on the affected side is smaller than the other testis. If none of those things occur, unless the varicocoele is small, at some point the man should have a semen analysis (sperm count) to determine if the count is low or if there are many abnormal sperm. If the semen analysis is abnormal that would also be an indication for surgery.

Sincerely,
Dr. Warren

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