Irritable Bowel Syndrome is one of the common functional bowel diseases that affect us. Intestinal diseases may be classified broadly into Organic and Functional, where Organic refers to structural intestinal disease as compared to Functional disease where an identifiable structural bowel problem like an ulcer or narrowing (stricture) or bulge (diverticula of the intestine) is absent. IBS is characterised by abdominal pain and altered bowel habits (constipation or diarrhoea).
People with IBS tend to have visceral hypersensitivity i.e., increased perception of pain on intestinal distension. Studies done on IBS patients have shown increased inflammatory/ immune cells in the intestines (on biopsy) such as lymphocytes, mast cells which secrete inflammatory cytokines, histamine, serotonin and other substances that stimulate the nerves inside the bowel wall (Myenteric plexus) and cause increased cellular permeability, pain and increased contractions of the intestinal muscle leading to diarrhoea. This could be the cause for the so called post infectious IBS that is associated with bacterial, viral, protozoal and helminthic infections. There is also a theory that composition of fecal microbiota could be associated with the development of IBS. Small intestinal bacterial overgrowth (SIBO) also has an association with IBS. Studies done have shown that people with IBS have abnormal breath tests indicating bacterial overgrowth and gets better with antibiotc treatment which can reduce the bacterial population. Food allergies, carbohydrate indigestion and gluten sensitivty are also attributed as causes for IBS. Genetic causes, psychological causes such as anxiety depression phobias and somatization have also been shown to be risk factors for IBS development.
IBS is usally suspected when symptoms of abdominal pain and altered bowel habits persist for more than 3 months. The following are typical features of IBS: The symptoms could be either intermittent or continuous.
1. Abdominal pain for atleast 1 day a week. It is usually lower abdominal.
2. Changes in stool frequency – Constipation or diarrhoea
3. Changes in stool form – lumpy hard, pellet like or tooth paste like or loose and watery!
4. Change in stool passage – urgency, need to strain or having a feeling of incomplete evacuation
5. Bloating of abdomen.
6. Association with depression, anxiety, chronic stress or somatization.
What features would suggest that IBS is UNLIKELY!
1. Alarm symptoms such as alternating constipation with diarrhoea, blood in stools, nocturnal diarrhoea, weight loss and fever might indicate a more sinister pathology such as cancer or Inflammatory Bowel disease.
2. An Acute onset might suggest an infective cause for the symptoms.
Such people with the above features and those with a family history of cancer, Inflammatory Bowel disease or Coeliac disease would need other investigations such as Colonoscopy and biopsy.
IBS is classified into 4 types. IBS with diarrhoea (bowel movement > 3 /day), IBS with constipation (bowel movement < 3/week) , IBS with both diarrhoea and constipation and IBS that is not subtyped.
A complete blood count, ESR, CRP, stool complete and occult blood test, Stool calprotectin and and a sigmoidoscopy and colonoscopy may be done (for those with alarm features only) are some of the tests that may need to be done for someone suspected to have IBS.
IBS is a chronic disorder and therefore education and reassurance go a long way in helping the patient cope with the disorder. IBS is prone to recur with periodic exacerbations and remissions. Moderate exercise is believed to be helpful. Avoidance of gas causing food may also help. A diet low in FODMAPS (fermentable oligo, di, mono sacharides and polyols may be helpful. Restriction for 2-4 weeks may improve symptoms. The FODMAPs include 6 food groups:
1. Fructose – corn syrup, apple, pear, watermelon and raisins.
2. Fructans – garlic, onions, leeks, asparagus and antichokes.
3. Wheat based foods – breads, pasta, cereals, cakes.
4. Sorbitol – stone fruits
5. Raffinose – legumes, lentils, brussel sprouts, soybean and cabbage.
Many pharmacologic agents (medicines) are being used to treat IBS.
Antispasmodics such as hyoscyamine, dicyclomine and mebeverine and Probiotics are used for abdominal pain.
Loperamide can be used for diarrhoea.
Polyethylene glycol 3350 is used for constipation predominent IBS. Newer medicines such as Lubiprostone, Linaclotide, Plecanatide and Tegaserod are also used for the same condition. Antidepressants such as Tricyclics and SSRI are also useful. Rifaxamin, a non-absorbable antibiotic is used with good effect for bloating.
Cognitive behaviour therapy, yoga, relaxation and hypnotherapy is also believed to be helpful.
Fatigue is not an uncommon complaint that a doctor hears at his clinic. This term however could mean many things to many people. While there are many normal causes for fatigue and tiredness, I would like to write about the abnormal (pathological, disease related) causes for tiredness that the reader needs to be aware of.
Fatigue could happen normally from doing unaccustomed severe exertion or exercise or due to inadequate rest and recovery after exertion, sleep deprivation, travel thorough different time zones (Jet lag) or due to obesity, under nutrition and severe emotional stress. You could recover from fatigue from the above causes by taking adequate rest. So why should fatigue persist even after taking enough rest and what could the reasons be for it?
Pathological fatigue has many causes. Broadly they may be grouped into the following categories.
Significant Fatigue is when fatigue persists for at least 2 weeks and can affect upto 25% of the population at some time. Chronic sleep deprivation (sleep apnoea) can also be a cause for severe fatigue.
Chronic Fatigue is when fatigue affects the person for more than 6 months.
Alarm signs in Chronic fatigue:
1. Anorexia and weight loss (>10% per 6 months)
2. Enlarged Lymph nodes.
3. Memory and concentration impairment
4. Inability to function due to myalgias, arthralgias, headaches etc.
5. Deep depression
Evaluation of complaints of Fatigue:
Treatment of Fatigue
Identification and treatment of the cause for fatigue will cure the problem most of the times`.
Interventions that may be of benefit for people with problematic fatigue are:
1. To fix lifestyle abnormalities – to regulate lifestyle, to eat, sleep on time.To exercise regularly – resistance as well as aerobic training reduce fatigue. (Graded exercise programme)
2. Use of nocturnal cPAP for those with Obstructive Sleep Apnoea
3. Medications – Melatonin or nocturnal sedatives
– Modafinil or Armodafinil
– Testosterone replacement therapy for those with deficiency
– Steroid replacement therapy for those with adrenaline insufficiency
– Correction of Vit D and other vitamin deficiencies.
4. Cognitive Behaviour therapy provided by an experienced psychologist.
A note of Long Covid Syndrome:
Covid 19 infection has been the most common cause for prolonged fatigue over the past 2 years. Long covid syndrome refers to the persistence of symptoms many weeks after the acute infection. Fatigue is a persisting symptom irrespective of the severity of the infection. In one study 92% of covid patients had fatigue 79 days after the onset of Covid infection.
Common symptoms of long covid include:
Fatigue,breathlessness, chest pain,mental fudge and cognitive abnormalities, sleeplessness, smell and taste abnormalities, headache and feverishness etc. Treatment is essentially symptomatic only.
I am currently reading a book called The Anarchy by William Dalrymple, a book detailing a state of anarchy existing in India in the eighteenth century which made it easy for the British East India company to defeat the ruling Kings and take over the country. Apparently at the time when Lord Cornwallis ran the EIC, Britain had lost its American colonies to the descendants of the original european settlers (and not the locals). In India, one in three British men were “cohabiting” with Indian women and it was believed that there were 11000 Anglo-Indians living in the 3 Presidency towns ( Madras, Calcutta and Bombay). Fearful of losing their Indian territories in the future to the descendants of British men, the EIC banned all Anglo-Indians “orphans” from serving in the company army (as well as in the civil and marine branches of the EIC) and from owning land thereby excluding them from most lucrative sources of employment. They were only allowed to work as pipers, drummers and farriers in the company army and were further demoted to holding minor jobs as clerks, postmen and train drivers. The Anglo- Indian community was therefore relegated to the fringes of Indian society where they developed their own unique culture and spoke English in their own unique style. My father had told me many years ago that “bloody” and “bugger” were words used primarily by the Anglo-Indian communtiy and that it subsequently become common usage. I remember using these words without knowing their meaning as a child, at home in front of my parents and never being corrected or admonished. So kindly excuse my use of those words in this article.
So, this article is written to give you more information of the common causes for anaemia, why they happen and give you some information as to what you can do about it. I write this article from my perspective and experience as a doctor practising in an urban setting in South India.
Low hemoglobin in referred to as Anaemia. Men are anaemic if their hemoglobin in less than 13.6 gm/dl (hematocrit <41%) and in women if hemoglobin is less than 12gm/dl (hematocrit <36%). Worldover, the commonest cause for anemia is Iron deficiency.
Hemoglobin serves the very important function of carrying Oxygen to all the tissues. Oxygen is picked up in the lungs and delivered to the tissues in every corner of the body. Therefore when anemic, the person may feel breathless on exertion (or even at rest when severe), tired, dizzy with chest pain, cold extremities and pallor. The person could also be absolutely asymptomatic especially if the anemia develops gradually over several months or years.
The cause of the anemia could vary according to the age at detection. In children, Nutritional Iron, B12 and folate deficiency, Hook worm infestation, Hemolysis and heriditary causes (Thalassemia or Sickle cell anemia) may occur.
In adults, Iron deficiency due to Acute or chronic blood loss (menstrual blood loss, Gastrointestinal bleeding from piles, stomach ulcers etc worsened by antiplatelet drugs such as Aspirin or Clopidogrel), Kidney failure, chronic diseases and Cancer chemotherapy.
In the elderly, anemia can be caused by Chronic diseases, Iron deficiency (from gastrointestinal blood loss), Vit B12/Folate deficiency, Chronic leukaemia and cancers, Myelodysplastic disorders and blood loss (acute from fractures after falls and chronic from intestinal bleeding).
Broadly Anaemia can be divided into the following categories:
Reduced production of blood
Deficiency Anaemia – Iron, B12 and Folate.
Bone marrow disease – Acute and Chronic leukaemia, lymphomas and other bone marrow malignancies, Aplastic anaemia, Myelodysplastic syndrome, Myelofibrosis and Infections affecting the bone marrow.
All blood cells are produced in the bone marrow and any disease that affects the bone marrow can cause anaemia.
Anaemia of Chronic disease – Chronic disease such as Inflammatory bowel disease, Rheumatoid arthritis affect the transfer of iron from the immune cells to the bone marrow.
Anaemia of Kidney failure – the kidneys produce Erythropoietin, a hormone that stimulates the bone marrow to produce blood. When this stimulus reduces due to kidney failure,anaemia ensues.
Increased Blood destruction or loss
Blood loss – acute and chronic.
Hemolytic – Heriditary (Hemoglobinopathies), Autoimmune, Enzyme defects(G6PD), MAHA
Malaria
Overactive spleen (Hypersplenism)
So how do you go about finding out the cause for your anaemia?
The following tests would be useful.
The CBC – complete blood count
Hemoglobin levels – based on the hemoglobin levels anaemia can be classifed as mild (>10gm/dl) moderate (7-10gm/dl) and severe ( <7gm/dl).
MCV – mean corpuscular volume
– A low MCV occurs frequently in Iron deficiency and a high value >100 in Vit B12 and folate deficiency.
Platelet counts – are reduced in acute infections and Vit B12 and folate deficiency and Bone marrow disease. A high platelet count is seen in Acute as well as chronic blood loss.
ESR – increases in all Anaemias.
CRP – increases in all inflammatory and infective conditions.
Reticulocyte count and index – A normal or increased Reticulocyte count and index indicates a functioning bone marrow and could indicate blood loss or hemolysis as a cause for the anaemia.
Peripheral smear – especially reported by a human rather than an automated machine will give a very valuable information regarding the cause for anaemia.
Iron study – Serum Iron, Transferrin saturation and Ferritin – Low serum iron, low transferrin saturation (low TIBC) and a low Ferritin indicate iron deficiency. A normal or high iron, normal or low saturation and a high Ferritin level would indicate Chronic infection and inflammation.
Serum LDH – lactate dehydrogenase – rises in hemolytic anaemias and other hematoloic conditions.
Stool for occult blood – positive report would indicate gastrointestinal blood loss.
Serum Vit B12 and folate levels – are reduced in Megaloblastic (macrocytic) anaemia due to B12 and folate deficiencies.
Renal function test – Urea and creatinine – Creatinine levels > 4 mg/dl may indicate a renal cause for Anaemia.
Other tests:
Haemoglobin electrophoresis – can help diagnose Thalassaemias.
Bone marrow aspiration and biopsy study – Will indicate if an underactive bone marrow is the cause for the anaemia.
Osmotic fragility – Increases in Heriditary spherocytosis.
Coombs test – is positive in Autoimmune Hemolytic anaemias.
Normal blood smear showing RBC with central pallor (1/3 diameter of the cell). The large purple cells are the white cells and the small ones (11’o clock position) are the platelets.The smear above shows iron deficiency anemia, the central hollow is more than a 1/3rd of the whole red cell. The red cells are of smaller sizes and different shapes.The smear above show megalobalstic (macrocytic) anemia with large red cells and hypersegmented Neutrophils in the lower centredue to Vit B12 or Folate deficiency.
Case studies: Lets have a look at a few case stories from my practice.
1. Mrs. M was a 38 yr old lady who was seen by her gynaecologist for anemia and was prescribed iron tablets as emperic treatment of Iron deficiency anemia due to menstrual blood loss.I had seen her a month later for severe abdominal pain and constipation.As her stool occult blood test returned positive, a colonscopy was done and it showed a large growth nearly occluding the rectal lumen (and she had been absolutely asymptomatic till then).She underwent surgery to relieve obstruction and later succumbed to the cancer despite best therapy.
Moral of the story- every case of suspected anaemia needs relevant investigations!
2. Mr. A was a 21 yr old man studying in Canada. He was my patient since the age of 16yr and his parents were always unhappy that he was a poor eater and liked only junk food like pizzas and bread! He was brought to my clinic by his father who was concerned that his son looked weak, the blood tests done revealed anemia which was thought to be due to iron deficiency as it was of the microcytic type.I ran a set of tests on him which showed that his iron levels were normal. A Hemoglobin electrophoresis test done revealed Thalassaemia minor. In this case giving iron tablets would have been the wrong thing to do.
Moral of the story- every case of anemia needs relevant investigations!
3. Mr.S was a 36 yr old patient of chronic deforming Rheumatoid arthritis. He gave a history of previous blood transfusions for anaemia and of regular intake of pain killing tablets for his joint pains. His Hemoglobin was 3.5gm/dl, ESR and CRP were very elevated, the iron study revealed low iron and elevated ferritin levels and the stool occult blood test was negative. He was diagnosed to have anemia of chronic disease. He was transfused to hemoglobin of 8gm and was started on DMARDS for his Rheumatoid arthritis.
Moral of the story – not every case of anemia is due to Iron deficiency.
4. Mr. H was a reformed alcoholic who came with complaints of weakness and tiredness. His examination revealed signs of chronic alcoholic liver disease with ascites (abdominal swelling due to fluid collection). Investigations revealed moderate anemia with hemoglobin of 8gm/dl, pancytopaenia (reduction of Red cells i.e., anaemia, white cells and platelets) and fecal occult blood test was positive. He was diagnosed to have anemia due to hypersplenism and due to GI blood loss. The patient was transfused to a hemoglobin of 10gm/dl, his coagulation disorder was corrected and he had a endoscopic procedure to treat his bleeding varices.
Moral of the story – your doctor can find clues to the cause of anemia. So if you are anemic, go see your doctor and get it corrected.
5. Mr. N came to see me with some dyspeptic symptoms. His hemoglobin was 8gm/dl and his MCV was 105. His peripheral smear showed macrocytic anaemia suggestive of megaloblastic anemia with hypersegmented nuclei on Neutrophils. He tested postive for anti Intrinsic factor antibodies, his vit B12 levels were very low and an endoscopy done revealed atrophic gastritis. He was diagnosed to have Pernicious anemia due to Vit B12 deficiency and was given IM injections of Vit B12 after which his hemoglobin returned to normal.
Take home message: If you are anaemic, get some tests done, see your doctor before you start giving any excuses to explain why you are anemic.
Sleep is a recurring natural state of mind and body characterised by reduced consciousness, reduced sensory activity and perception, reduced muscle activity (increased muscle relaxation) and consequently reduced interactions with the surroundings.
Sleep is essential for all animals and is when the body builds up, restores energy and every other system (muscular, nervous, endocrine and immune systems) during this period of rest. Inadequate quantity and quality of sleep can lead to a variety of diseases including diabetes, heart disease, strokes, obesity and depression and other psychiatric disorders.
Modern living with long working hours, working through the night, travelling through various time zones, use of various electronic gadgets (Blue light emitted by mobile phones tablets and laptops supposedly inhibit the release of the sleep hormone melatonin) disrupt normal sleep and lead to typical stress related disorders.
While each person requires different amounts of sleep, on an average a 40 yr old needs 7 hr every night, 6 1/2 hrs of sleep at ages 45-60 and about 6 hrs or less at the age of 80 yrs and above.
Sleep occurs in cycles that last 90-110mins (i.e., less than 2 hr). Each cycle has 2 types of sleep, NREM (non rapid eye movement or slow wave sleep) and REM (Rapid eye movement sleep). NREM has 4 stages 1,2,3 &4). When we close our eyes to sleep , we are in stage 1 and we gradually move into the other stages as we continue to sleep. Stages 1 and 2 are the lighter planes of sleep and 3 and 4 are the deeper planes. Throughout each stage the body relaxes progressively and the EEG (brain activity) changes and slows down.
REM sleep deprivation leads to sleep that is not restful. More time is spent in stage 3-4 during the first half of the sleep period. In the second half, more REM sleep happens as shown in the diagram. As REM sleep is most restful, staying awake during this period (between midnight to 4AM) has health consequences. Younger children especially newborns spend much longer times in stage 4 sleep and REM sleep. REM sleep duration reduces with ageing to much less than the 25% enjoyed by young adults.
You may have a sleep disorder if you have trouble falling asleep when you lie down in bed, if you wake up feeling tired and if you tend to doze off during the day especially during work.I had a friend who fell asleep at the wheels of his car and had a serious accident. If these are issues for you, the question may arise if you should buy a smart device to track your sleep. Unfortunately most of these devices that are worn on the wrist are not medically validated to diagnose sleep disorders. Most of them detect body movements or in some cases the heart rate and its variability, to decide if you are asleep or awake. These devices could get fooled into believing that some insomniacs are asleep when they have their eyes closed, body relaxed and are in bed waiting to fall asleep. So while these devices may be accurate in detecting duration of sleep (based on movements etc), they can be quite inaccurate when they calculate the time spent in the different stages of sleep and also when they make assumptions about the quality of sleep. My smart device suggested that I had sleep apnoe when it detected that I woke up 20-25 times during the night. As I didnt have any symptoms of a sleep disorder, I concluded that it probably detected my movements in bed and inferred that I had woken up. The sleep specialist whom I discussed this also came to the same conclusion. On the other hand, validated sleep study devices (Polysomnography) monitor various parametes such as EEG, ECG, Muscle tone, chest and abdominal movememts, O2 saturation and limb movements to give a detailed analysis of sleep. Compared to these devices, sleep trackers are only 78% accurate in detecting sleep vs wakefulness, 38% accurate in identifying exactly how long it took to fall asleep and only about 50% accurate in detecting the various stages of sleep (including REM sleep).
So should you by a sleep tracker? I believe that anything that is measured, improves. Therefore if you aren’t sleeping well, it may be a good idea to buy a sleep tracker. Many of these devices also measure your heart rate during sleep and an increasing RHR (resting heart rate) may also be indicative on a non-restful sleep.
I have used the Samsung Galaxy watch 3 which is excellent for sleep monitoring and the apple watch which is more accurate for heart rate monitoring (especially during exercise). So go ahead and buy a smart watch that can track your sleep, focus on all the things that you need to do to stay healthy and get healthier!
Pain in the throat can happen from many reasons. Although people may refer to the neck as the throat, what doctors consider as throat is the pharynx and the tonsillar areas. Lets have a look at the anatomy of the throat and then see how things change in disease.
The throat or pharynx is a muscular tube that connects the mouth and the nose to the windpipe (trachea) in the front and the food pipe (Oesophagus) behind. It is divided into 3 parts, the upper Nasopharynx (the part behind the nose), the Oropharnx (the part behind the mouth) and the Laryngopharynx (the lower most part behind the larynx (the voice box).
The throat or the Oropharynx is bordered by the palate on the top, the pharyngeal pillars (tonsillar areas) on the sides and the tongue below. This is the most important gateway into both the Respiratory as well as the Gastrointestinal tract and is therefore a site for frequent infections.
A sore throat occurs whenever there is inflammation in the throat. Inflammation could be due to infection or a non-infectious cause. Lets look at some of the common and not so common causes for a sore throat.
1. Viral Pharyngitis – the most common cause for a sore throat after streptococcal infection is a viral pharyngitis. This season, the commonest cause is the Covid 19 infection which causes severe and painful sore throat. Unlike a bacterial infection, the patient will have a runny nose, the throat will be erythematous (reddened) and would not show any pus points. Infectious mononucleosis (kissing disease)is seen in young patients who catch infection from kissing. The pain is often out of proportion to the severity of the pharyngitis on examination. This infection can be associated with a rash, enlarged lymph nodes in the neck and an enlarged liver and spleen. The blood smear study would show typical large lymphocytes (increased Lymphocyte count) The treatment is essentially symptomatic.
2. Bacterial (streptococcal pharyngitis and tonsillitis)
The throat shows small petichiae (bleeding spots) on the palate. If tonsillitis coexists, the tonsils are enlarged and show pus oozing from them and the lymph nodes in the neck are enlarged. Streptococcal infection is the commonest cause for a sore throat even more common than viruses. Recurrent streptococcal infection may predispose patients to Rheumatic fever and cardiac disease. Bacterial pharyngitis may also be caused by Neisseria gonorrhoea, Mycoplasma and chlamydia species. Antibiotics would be needed in many cases.
3. Peri-tonsillar abscess (Quinsy)- when the infection spreads through the capsule of the tonsil, pus collects outsides the tonsil and displaces the tonsil inwards, nearly occluding the oral cavity.Peritonsillar abscess must be treated with antibiotics and may need a drainage procedure to remove the pus and to hasten
4. Diphtheria is a respiratory tract infection that cause severe pharyngitis with a thick membrane over the throat. This can be dangerous if left untreated. Prompt antibiotic therapy will be needed.
5.Oral thrush is causes by yeast like fungus called candida. This is also quite common. It is seen on those on broad spectrum antibiotics, diabetes, steroid therapy, immune compromising conditions including HIV infection. The white patches can easily be dislodged showing underlying erythema (redness) and inflammation. Anti-fungal lozenges will be very effective in its treatment along with treating the cause for the infection e.g., controlling the blood sugars and stopping the antibiotics.
Non- infective causes for a Sore throat
1. Acid Reflux with pharyngitis – this is a very common cause for chronic pharyngitis. Acid reflux is a lifestyle disease caused due to an incompetence of the gastro-oesophageal valve usually seen in obese individuals who overeat.
2. Oral aphthous ulcers, Lichen planus, pemphigus and pemphigoid, Behcets syndrome and drug reactions can also give severe sore throat. Rarely cancer can be a cause for a sore throat. The photo below shows large ulcers of pemphgus.The photo below shows a larger ulcer from cancer of the mouth.
So if your throat is sore and you have difficulty swallowing food, please consult your doctor for advice. Once the cause for the sore throat is identified, specific treatments are given to hasten recovery. Most infective sore throats respond well to antiinflammatory medicines such as Brufen. Antibiotics will be given by your doctor as necessary. Specialist consultation may also be needed.
The heading of this article must sound strange but I have been pushed to write this article after another of my patients came back from Thailand, all stressed out and looking depressed. This young man had gone to Thailand with a few of his friends and had had a “regrettable” encounter with a commercial sex worker! During the course of my 25 yrs as a doctor, I have seen many a good man being remorseful after coming to his senses and (out of his alcohol or drug induced fugue) filled with guilt and fear on returning to his wife and life in Chennai. I write this article for the benefit of someone planning on being naughty on a holiday and hopefully, to give you enough information to help you stay safe during your trip.
What are the common sexually transmitted infections?
Syphilis, Gonorrhoea, Chancroid (Bacterial infections), Lymphoma granuloma venereum (Chlamydial infection), HIV, Genital herpes (HSV), Genital warts (HPV) (viral infections) and Trichomonas vaginalis (protozoal). Hepatitis A, B, C and pubic lice can also be transmitted during sex. HIV chlamydia and gonorrhoea are transmitted by sexual (body) fluid, HIV and Hepatitis B are transmitted via blood and Genital herpes, papilloma viruses and Syphilis are transmitted by skin to skin contact. Except for HIV, all STIs are curable if detected.
What are the risks of transmission of STD after a single heterosexual encounter?
The risks for women are much higher than it is for men. Syphilis has a 50-65% risk per sexual act, Gonorrhoea has a 20% risk for men and 60-90% risk for women to catch an STI after a single unprotected sexual act. Chlamydia has a 4.5% risk per sexual act and Mycoplasma has a 20-65% risk. HPV and genital warts are transmitted 4% for men and 3.5% for women after a single sexual act. The risks for HIV transmission is 0.05-0.1% for men and 0.08-0.19% for women after a single act. Receptive anal and vaginal intercourse has a 10 fold increased risk of infection transmission compared to Insertive anal and vaginal intercourse. Luckily the risk of catching HIV is a lot lower than for other infections. You should consider all sexual encounters with people not known to you in a foreign country as a high risk (for infection) encounter. Receptive Anal/Vaginal sex is more dangerous for catching an STI compared to Insertive sex and oral sex!
How soon will you see the effects if you catch any of the common infections?
Different infections have different incubation periods ( the time taken for the first symptom after entry of the pathogen into the body i.e., infection).
So what symptoms should you look for in case you have had an unprotected sexual encounter?
Common symptoms to look out for are Genital ulcers, enlarged lymph nodes in the groin, urethral discharge with burning on urination, vaginal discharge and fever, body aches, joint aches, headaches and rash etc. Most symptoms would show up a few days to upto a month after unprotected intercourse.
What tests are useful in the diagnosis of STIs?
Swabs from ulcers, from mucous membranes of the penis, vagina and mouth. Serological tests (to check for antibodies to certain infections) can be done for Chlamydia, syphilis and for HIV.
For syphilis, TPHA and FTA-ABS can be done. Nuclear antigen amplification tests or PCR can be done for HIV, Chlamydia, Chancroid, Gonorrhoea, Herpes, Trichomonas, Candida and bacterial vaginosis can be done. Biopsy can be done for genital warts.
What antibiotics are useful after unprotected sexual intercourse?
Azithromycin 1gm stat will treat Chlamydial infections and Chancroid.
Doxycycline 100mg twice daily for 14 days for Syphilis and Donovanosis.
Valacyclovir 1gm twice daily for 10 days for Genital Herpes.
Fluconazole 200mg at night for 3 days for Candidal infections.
Metronidazole 500mg twice daily for 7 days for Trichomoniasis.
Inj. Ceftrioxone 500mg IM stat for Gonococcal infection.
Inj. Benzathine penicillin 2.4 MU IM stat for primary syphilis.
Taffic (Bictegravir 50/Emtricitabine 200/Tenofovir Alafenamide 25) once daily or Viropil (Dolutegravir 50/Lamivudine 300/Tenofovir Disoproxil fumarate 300) once daily for 28 days, to be started as soon as you suspect that you may have caught HIV infection.
How do you protect yourself from catching a STI/STD?
1. Avoid going to places of temptation in the first place. If you must, take your spouse along with you!
2. Avoid mixing alcohol and drugs with sex. These substance will reduce your inhibitions and fear and make you do things that you wouldn’t do if you were in your senses.
3. Limit the number of sexual partners.
4. Use barrier methods of contraception. Use condoms, oral dams etc and avoid skin on skin contact and exchange of body fluids. Oral sex isn’t safe!
5. Get to know your partner before hand and if possible have an honest talk about previous sexual contacts, sexual habits and preferences and history of previous STIs.
6. Get yourself vaccinated against all possible sexually transmitted infections such as Hepatitis A and B, Human Papilloma virus etc.
7. Test yourself regularly especially if you have had numerous sexual contacts with multiple partners.
To sex or not to sex, that is the question you need to ask yourself! (All pun intended) If you choose to have sex, take all necessary precautions. If you have had unsafe sex or if you can’t remember, see your doctor as soon as you return and start relevant prophylactic medicines (as no test will be positive in early infection especially when you are asymptomatic).
As a doctor I have always been interested in knowing the secrets to a long life. Many people who lives long lives have very few if any diseases, apart from an old body (if you can consider that a disease) and remain surprisingly sprightly even in their 90s. Many others bravely tackle their medical and age related challenges and live a long life aided by modern medical treatments. So it was extremely exciting to find an article in The National Geographic Traveller magazine (Indian edition -May June 2022) which spoke about food and lifestyle habits of people who had a greater chance of living long lives (Centenarians) in certain areas of the world. The article quoted from research done by Dan Buettner, a longevity researcher who called the 5 specific areas of the world, where people were more likely to live up to a 100 yrs, the BLUE ZONES. The article seemed to suggest that these elderly people were living long lives because they were healthy rather than because of modern medicine.
These geographic areas are the following:
1. Greece- Icaria
2. Italy – Ogliastra, Barbagia, Seulo of Sardinia.
3. Japan -Okinawa.
4. Costa Rica – Nicola peninsula
5. USA – Loma Linda, California (Seventh day Adventists)
While the article highlighted the various food cultures of the people in these areas, I was more interested in Buettners “Power of Nine”,the factors/cultural/societal habits that were common to the people who lived in these 5 areas. Lets have a look at these habits.
1. Moving naturally – daily walking and gardening.
2. Purpose – motivation to get up in the morning.
3. Down shift – activities like prayer, meditation and naps and evening drinks with friends)
4. The 80% rule – to always eat only until 80% full.
5. Plant slant – significant portions of beans and greens and small portions of meat.
6. Wine @5 – moderate drinking.
7. Belong – to be part of some faith based community.
8. Loved ones first – to have close family ties.
9. Right tribe – strong social circles.
Many of these points are what I suggest to patients who have clinical depression. It would seem that happiness could be the answer for a long life if one were to remain physically active and eat right ( if you have read about what my grandfather had told me mentioned in my earlier article on longevity). Stress release by exercise and being physically active, stress control by meditation and living in a supportive/encouraging and positive social environment and consuming moderate amounts of alcohol could hold the key to a long life.
I hope and pray that you will incorporate these factors into your life and live long!
Most of us would have at some point had a severe ear ache or seen someone else (usually a child) crying out in severe ear pain. The article will provide you with some information on the common causes and what you can do if you have someone with a earache to look after. Of the common causes for ear ache the first 4 conditions are more common in children and the last few ones are commoner in adults. Before that, lets have a quick look at the anatomy of the ear to get a better understanding of the problem.
The external ear or the Pinna behaves like a funnel collecting the sound waves from outside the body and directing it inside the ear where they hit the eardrum and make it vibrate. The portion of the ear upto the eardrum (from the outside) is called the External ear. Touching the eardrum are bones that sequentially transmit the vibration to the snail like Cochlea which is the organ that converts the sound vibration to electrical impulse which is conducted by the auditory nerve to the brain where the electrical impulse is interpreted as meaningful sound/voice/music or noice. In the diagram above, the 3 bones that conduct sound waves to the cochlea (i.e., Malleus Incus and Stapes) lie in the middle ear and this chamber is connected to the back of the throat by the Eustachian tube (in pink). The Eustachian tube maintains equal pressure on both sides of the ear drum permitting free undampened vibrations of the ear drum to incident sound. The inner ear (found deep inside the bone) also contains the organs of balance – Utricle and saccule and the semicircular canals.
Therefore the ear has 2 functions – hearing and balance!
Conditions causing Ear ache
1. Otitis externa (External ear infection) – is usually caused by trauma or injury caused by over enthusiastic ear cleaning with the finger or the ear bud. Less frequently it can happen after a swim in the pool. The tissues of the outer ear are tightly attached to the underlying bone and therefore any infection or boil, produces severe pain. The ear lobe could be red and swollen. Looking into the ear with a torch may show the boil or if pressing on the tragus (the small prominence just in front of the opening into the ear) or pulling the ear give severe pain – this would also indicate external ear infection. This would need antibiotic ear drops prescribed by your doctor.
2. Shining a light into the ear may also show an insect that can be the cause for pain. Shining a bright light may draw the insect out. Please don’t put oil into the ear (especially if you know that the ear drum is perforated)
3. Eustachian tube dysfunction – When the person has a mild cold, the excess mucous secreted may occlude the Eustachian tube. The air in the middle year then get absorbed and this negative pressure would draw the eardrum insides and reduce its vibrations to sound. Therefore people may have a feeling of reduced hearing. This is very common during a aeroplane flight. Sudden changes in altitude can even cause rupture of the ear drum (Barotrauma). The ear could pop open on yawning or blowing out with a pinched nose giving some relief. Using a nasal decongestant drop or using Vicks inhaler might help. Eustachian tube dysfunction commonly occurs in those with respiratory allergies, dust exposure and infections. If this condition doesn’t resolve, persisting negative pressure may draw out the fluid into the middle ear from the blood vessels causing serous otitis media. If bacteria invade and proliferate here, it becomes Acute suppurative (pus producing) Otitis media (middle ear infection).
4. Acute Suppurative Otitis media (ASOM) – this often presents with severe ear pain, reduced hearing and often with fever. Pulling on the ear or looking into the ear would not give severe pain. Sometimes there could be a spontaneous rupture of the ear drum and release of copious pus from the ear, also relieving the pain to an extent. This condition requires specific antibiotics and requires you to go to the local ENT surgeon for advice. If inadequately treated, the infection could become chronic (CSOM) and also spread inwards to the bone and the brain.
5. Herpes Zoster Oticus – relapse of the chicken pox virus affecting the ear could be a cause for severe earache with a rash around the ear. It may also cause hearing loss, ringing in the ear, vertigo, difficulty in closing the eye and a dry mouth.
6. TMJ Dysfunction – Temperomandibular joint is formed between the jaw bone and the undersurface of the skull. People who have a habit of biting only on one side or grinding their teeth can develop pain around the ear. This pain would be worse on opening the mouth widely and on chewing.
7. Pain referred to the ear due to stimulation of commonly innervated body parts- The tonsil and the ear may be supplied by the same nerve (the glossopharyngeal Nerve) Therefore irritation of the nerve due to Tonsillitis would cause pain to be referred to the ear. Similarly other nerves such as the Trigeminal, Facial, Vagal and somatic cervical nerves may also in certain conditions cause an earache.
Take home points:
Any medicine that you have taken for pain before would work to relieve an ear ache. Paracetamol or any other anti-inflammatory medicine can be given until you see the doctor.
There are many causes for a red eye and most people get very alarmed on seeing a very red eye. This article hopes to share some information about the common causes for a red eye and what one should do after developing a red eye. Before we go into the causes and the a development of a red eye, lets briefly look at the anatomy of the eye in the picture below.
The eye is like a ball made of the tough sclera (white part of the eye) all around except in the very front of the eye where the transparent cornea is attached. The front part of the sclera is covered by the protective conjunctiva which folds under the eyelids. The conjunctiva has a rich supply of blood vessels and they open up whenever there is an irritation and make the eye red.
The cornea is the transparent window that allows the light inside the eye. The amount of light allowed in is controlled by the iris and its central opening called the pupil. The lens of the eye which is biconvex focuses the light on to the fovea , an area on the retina where light is transduced into electric impulses that are carried by the optic nerves for interpretation in the brain.The retina is the inner most layer (of nerves) inside of the sclera and is separated from the sclera by the vascular choroid layer.
The eye is an extremely sensitive organ and the body does everything to protect it. Therefore any irritation which may be due to injury, abrasions, allergy, infection immediately stimulates an increase in the blood flow into the eye to help contain and repair the damage sustained. So a red eye is an indicator that all is not well with the eye.
So when should you go immediately to an Ophthalmologist or to a Eye hospital?
You need to go immediately to an eye hospital if you have severe pain in the eye or if your vision is impaired or if your pupils are irregular. There are 6 conditions that should make you seek help immediately.
1. Severe conjunctivitis : the eyes would be red, painful and with a lot of pus like discharge from the affected eyes.
2. Corneal ulcer is an extremely painful condition and can happen due to accidentally touching the eye, rubbing the eye or due to some caustic fluid splash on the eye or due to herpetic infection. The eye will be red with excessive tearing and patient would find it difficult to open eye and look at light.
3. Uveitis – is when the iris and the ciliary body are inflamed due to an infection or any other condition. The eye will be red, painful with visual loss and inability to look into the light (Photophobia). On examination the pupils could be small and irregular and pus collection inside the eye may be made out (Hypopyon)
4. Acute angle closure glaucoma – can happen with those with farsightedness.The eye is filled with fluid that must be circulated. For many reasons when the drainage of this fluid is blocked the pressure increase inside the eye leading to the condition. The eye of such a person is red, very painful, vision is blurry, and nausea and vomiting may happen. On examination the cornea may be hazy and the pupil is dilated.
5. Herpes Zoster ophthalmicus- is a condition when the ophthalmic division is affected by the Varicella zoster virus (which causes chicken pox). Much after the initial chicken pox is overcome, the virus comes out of hiding along certain nerves to produce small vesicles on the skin. When this process affects the eye, it is a ophthalmic emergency.
6. Scleritis – also shows up with red painful eye with visual loss.
The way to approach a red eye when there are no worry signs is as follows-
1.Look out for discharge from the eye-if there is no discharge it could be sure to a sub conjunctival bleed which is usually seen in an elderly patients who may be on blood thinners and might have strained hard recently (or even after a bout of violent coughing or sneezing) This can
happen suddenly and may be noticed after a overnights sleep leading to severe anxiety.
2. If the discharge happens only intermittently- it could because of dry eyes, again something that is common in the elderly. Dry eyes can happen after prolonged screen times and in conditions such as Sjögren’s syndrome. Using artificial tears eye drops will make things much better.
3. If the discharge is continuous – to see if the discharge is watery or purulent (pus like).Pus like discharge always indicates infection and will get better with antibiotics (eye drops and tablets). If the watery eye discharge is associate with mild itching, it could be due to viral conjunctivits and if the itching is severe, it could be due to allergic conjunctivitis.
Take home message:
1. If the red eye is very painful, with visual loss and irregular pupil – rush to the Eye doctor/hospital.
2. If the red eye is not or minimally painful, with clear vision, mild irritation and discharge – you can probably wait till the next day before going to see an ophthalmologist.
3. If you are very anxious or in doubt – see the ophthalmologist immediately.
We all get headaches sometime or the other in our lives! I remember my first episode of migraine which I got when I was in 7th grade. My mother rightly diagnosed me to have migraine (being from a family of doctors), gave me some paracetamol and had asked me to go to sleep. I got my eyes checked a few days later, started wearing prescription glasses and never had migraine again for several years. My father told me that only intelligent people got a migraine and that made me very proud of my headache as none of my other siblings had a migraine till then. Apart from Migraine, one can have a headache from many causes such as head injuries, cervical spondylosis, dental caries, sinusitis, high BP,depression, malocclusion and Temperomandibular joint dysfunction etc.
So when should you go to the doctor and hospital immediately?
What are the danger signs in headache?
1. The worst headache in your life or a “bolt out of the blue” type of a headache.
2. Headache associated with slurred speech, visual disturbance, weakness of limbs, inability to walk due to loss of balance, confusion or memory loss.
3. Headache that happens after weight lifting or sex.
4. Headache after a head injury (however mild especially in the elderly)
5. Headache with recurrent vomiting.
6. Headache that wakes you up from sleep or is the worst after waking up in the morning.
7. If you have a chronic headache but its character and severity has changed recently.
Headaches may be classified as primary or secondary to other illnesses. The primary headaches are Migraine, Tension type and Cluster headaches. So lets look at the classic presentation of the common headache syndromes.
Migraine – this headache is usually episodic (can last for a few hours to 3 days) , usually unilateral, throbbing or pulsation and often associated with nausea, vomiting, visual disturbances (aura) and inability to look at the bright lights and handle loud sounds. Sufferers would usually prefer to lie still with their eye closed as the headache could be made worse by movement. Migraines are often precipitated by certain foods (cheese, chocolate, Agina Moto – MSG) sleep deprivation, hunger and stress. Migraine could get much better after sleep and after vomiting. A variety of medicines are available for the treatment of Acute Migraine and prophylaxis (preventive) therapies are available if the patient has more than 2 attacks of migraine a month.
Tension type Headache– this headache usually affects the back of the head and usually in the evenings. It may be associated with scalp tenderness and may be provoked by emotional stress, fatigue,notice and glare. Treatment of anxiety and depression may be needed.
Headache due to Sinusitis – headache due to sinusitis may feel more like head heaviness. The sinus are air pockets in the skull bones that are lined by mucous producing membranes and they drain the mucous produced into the back of the nose. They exist to make the head feel lighter and to provide resonance to the voice. When the drainage passages of the sinuses are blocked, they fill up with mucous, bacteria migrate into the sinuses and the mucous changes colour to yellow. Typically patients have a constant dripping from the sinuses into the back of the throat and there may be tenderness over the affected sinus. Sometimes the headache gets worse on ending downwards.
Cluster headaches are not so common. The headache is severe, unilateral, behind the eye and associated with a blocked or a runny nose on the same side and a red tearing eye. The headache can occur in clusters, lasting 15min to 3 hrs, daily for several days together. They can happen at night and wake the person up from sleep and can have specific triggers like migraine. But in contrast to migraine, the headache is non-throbbing/pulsatile.
Headache due to cervical spondylosis – severe spondylosis affecting the upper cervical vertebrae can give a severe headache which affects the back of the head right upto the vertex ( the top of the head on looking down). Movements of the neck are painful and could be restricted with neck stiffness.
Headaches due to a brain tumour– brain tumours increase the pressure in the brain and cause pain by displacing the pain sensitive structures. The headache is worse on lying down, can wake the person up from sleep or worsen and peak on waking after a nights sleep. Sometimes the headache can worsen after coughing or sneezing. The headache may be associated by visual disturbances or loss of balance, loss of power in limbs, confusion and memory disturbances.
Other headaches occur acutely due to a cerebrovascular catastrophe like a subarachnoid bleeding where it is severe, associated with vomiting, visual disturbance and abnormalities of consciousness. Meningitis can also cause a headache with fever and neck stiffness (inability to bend neck forwards)
Headaches can also occur with high BP usually above a systolic value of 180mmHg. The headache could be quite variable in character as well as in severity.
So what must you do if you have a headache?
The first thing is to see if it has any danger signs. If yes, please go to the emergency department of a good hospital. If not, you could take a paracetamol tablet, go to sleep and fix an appointment to see you doctor the next day. Most headaches are curable and they just require the doctor to find the best medicine for its control or cure.
Dr Subash Rau - General Physician’s blog 
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