Painful Testicle in Children (Acute Scrotum)

Painful Testicle in Children (Acute Scrotum)

Testicular pain known as acute scrotum can occur with or with our scrotal swelling or in the absence of redness. The common causes in children are as follows:

  • Torsion of epididymis or appendix of testis (60%)
  • Torsion of testis (30%)
  • Idiopathic scrotal oedema (< 5%)
  • Epididymitis or orchitis (< 5%)
  • Tumour
  • Trauma

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In all cases of acute scrotum, it is IMPORTANT to bring the child to see a paediatric surgeon as soon as possible as the testicle may die of ischemia (lack of oxygen) is the case of a testicle torsion if left untreated for more than 6-8 hours.

Torsion of the epididymis or appendix of testis
The epididymis or appendix of testis are embryonic remnants of the fallopian tube during the development of the child. These can cause torsion and the pain is felt at the upper pole of the testicle.

Torsion of the testis
Torsion of the testis affects 1 in 4,000 men. It is more common in boys who have a testicle which lies horizontally (as opposed to vertically in normal cases) known as a Bell clapper deformity. This position allows the testis room to twist around its spermatic cord causing severe pain and nausea or vomiting. It can occur at any age but more commonly between 12-18 years. Sometimes it can occur after a sports injury to the groin. This a medical emergency and requires prompt treatment.

Torsion of the testis can also occur in undescended testicle which will be felt as a tender lump in the groin.

Idiopathic Scrotal Oedema
There is swelling and redness on both scrotum with oedema but no pain.  The cause is not known but thought to be due to allergic reaction to insect bites.  Clinical examination and ultrasound test is required to make a diagnosis.  No surgery is required as the condition subsides within 2-4 days with medication such as anti-histamine.

Epididymitis
Epididymitis is due to infection from retrograde flow of bacteria from the urine (reflux) from the urethra. The epididymis is the coiled duct behind the testicle which carries the sperm. The child usually has fever or pain when passing urine with positive bacteria culture in the urine test. Antibiotics may be required to treat this condition.

Tumour
The most common tumour in the testicle is a teratoma which is hard and painless. There may be a family history of teratoma or a history of undescended testis. Clinical examination, ultrasound and MRI can differentiate a tumour from a torsion of the testis. Treatment is a combination of surgery and chemotherapy. Prognosis is good if the tumour is discovered early.

Reference: Cancer Research UK

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Peripheral Arterial Disease

Peripheral Arterial Disease

Peripheral arterial disease (PAD) occurs when there is a cholesterol plaque on the blood vessel walls causing them to narrow resulting in reduced circulation to the upper and more commonly lower limbs.

Who is at risk? 
It commonly affects people with type 2 diabetes especially when they have poor diabetic control. According to the American Diabetes Association, about 1 in 3 people with diabetes over the age of 50 have PAD. Other people at risk include smokers, older age, people with high cholesterol, overweight and having sedentary lifestyle with minimum or no exercise.

Symptoms and Signs
The symptoms depend on the extent of narrowing of the blood vessels.

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  • Initially, there will numbness or pins & needles in your legs and feet
  • Pain in your calf muscle after walking a short distance or even at rest
  • Sores on your feet or toes which heal slowly
  • Hair loss on the legs with shiny skin appearance
  • Cold feet with weak pulse

Image Source: Medicine Net

  • Toes or feet turning blue-black (gangrene)

Claudication pain is a reproducible pain at the calf muscle brought on by walking to a certain distance and relieved with rest but returns once the patient walks to the same distance. The pain occurs when there is not enough blood circulation to the leg during exercise.

How to prevent PAD
You can reduce your risk of developing PAD by changing to a healthier lifestyle and this includes:

  • stopping smoking immediately
  • controlling your blood sugar level (if you have diabetes)

Image Source: The Samaja

Image Source: Heart and Vascular Care

It is extremely important to treat the causes of PAD (as well as PAD itself) because if left untreated, there is a very high chance of the person getting a stroke or heart attack in the next 5 years.

How is PAD diagnosed?
1. Measuring the ankle-brachial index which is the ratio of blood pressure in the feet compared to the arm blood pressure.
2. Doppler ultrasound to measure the flow rate in the blood vessels in the feet and toes.
3. CT Angiography.

Treatment of PAD
Treatment of PAD has to achieve 2 goals:
(a) treat underlying risk factors to prevent further cholesterol plaque blockage
(b) treat the leg symptoms to reduce pain and prevent progression to gangrene

1. Angioplasty and stent insertion
This is a minimally invasive procedure to widen the blood vessel narrowing and also to place a stent to prevent the blood vessel from blocking again.

2. Open endarterectomy
Endarterectomy is required to remove the cholesterol plaque if the PAD is severe or the plaque is hard and large. The artery is then closed using stitches or with a patch made of your own vein or synthetic graft.

3. Bypass surgery 
In cases where the blockage is long and very hard (calcified), bypass surgery may be required whereby a graft (made up of either your own vein or synthetic graft) is used to create a new passage to flow around the blockage to the feet.

Follow-up foot care
Lifelong close regular follow-up surveillance is essential for all patients with PAD as the disease may recur. In addition to the lifestyle changes, you must also invest time to take of your feet with the help of a podiatrist. This is because any sore or injury heals slowly which increases the risk of infection.

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  • Wash your feet daily, dry them thoroughly and moisturise regularly to prevent cracks which can lead to infection
  • Wear well-fitting shoes and dry socks to prevent fungus growth

Image Source: WebMD

  • Treat any fungal infections of the feet (such as athlete’s foot) quickly
  • Take care when cutting your nails
  • Never walk barefoot out in the garden or beach

Download Teleme’s mobile app and connect with a Vascular Surgeon if you experience symptoms of PAD, a Podiatrist for foot care and a Fitness Coach to help you reduce weight by going on a supervised exercise program

Arterio-Venous Fistula: What to Expect and How to Look After

Arterio-Venous Fistula: What to Expect and How to Look After

Arterio-Venous Fistula (AVF) are created for patients with end-stage (stage 5) renal failure so their veins can be used for haemodialysis. Kidneys clean and filter your blood from waste and toxins but if you have lost more than 85% of your kidney function, you will need kidney dialysis to the work. The most common causes for kidney failure are diabetes, hypertension and auto-immune disease such as lupus (SLE).

Image Source: Diabetes Daily

In haemodialysis, the artificial kidney (haemodialyser) takes blood from your body, cleans the blood before returning the blood into your body. It also helps to maintain your blood pressure and balance important minerals such as sodium, potassium and calcium in your blood. The process usually takes around 4 hours and has to be repeated 3 times a week.  It may take longer depending on how heavy you are, how much kidney function and how much waste you have in your body.

Types of AVF

AVF allows the haemodialyser to get access to your blood. The surgeon will perform a minor surgery under local anaesthesia using your own vein (native AVF) or a prosthetic graft (synthetic AVF).

A successful native AVF can be used within 6-8 weeks when it is called a mature fistula. If the fistula does not mature after 2 months (called poor fistula maturation) and it can be matured via Balloon Assisted Maturation or open AVF repair procedure. Prosthetic graft fistulas take 2-3 weeks to mature.

Signs of AVF not working well

  • Infection (watch out for redness, warm feeling over the fistula area or pus)
  • Blockage (watch out for swelling of your arm and hand)
  • ‘Steal syndrome’ whereby blood is directed away from your hand (watch out for numbness or pain in the hand)

Photo of Graft Infection

Take good care of your AVF

Your AVF vein access is your lifeline and you must do your part to look after it. Wash the area around the AVF with soap and warm water every day. When blood is flowing through your AVF, you can feel a vibration over the area which means it is working well. Inform your dialysis nurse or doctor if you notice any changes so that action can be taken to save the AVF.

Download TELEME app and connect with your Vascular Surgeon or your nephrologist if you experience signs of arterio-venous fistula problem

Meal Planning Strategies for Diabetes

Meal Planning Strategies for Diabetes

These are important considerations when drawing up a diabetic meal plan:

  • Timing of meals and snacks. In general, diabetic should take more frequent but smaller sized meals. Patients on insulin may need a bed time snack to prevent night time hypoglycaemia or an additional afternoon snack. DO NOT go for no more than 4 hours without eating
  • Remove refined carbohydrates and added sugars from your diet. This means less fast foods and more home cooked meals where you know every ingredient that goes into your meal

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  • Include healthy food types such as complex carbohydrates (whole grain), fibre (vegetables and fruits), lean protein (fish and chicken)
  • Follow ‘plate method’ to estimate portion sizes
  • Keep a food diary by either taking photos or documenting the meals eaten to discuss with your dietician

Here are few choices of meal plan strategies for diabetic patients:

Choice A: Constant Carbohydrate Meal Plan

Image Source: Diabetic News Now

This meal plan is inclusive of counting grams of carbohydrate a person with diabetic needs daily. The carbohydrate is then distributed evenly at mealtimes. In the constant carbohydrate meal plan, consistency in keeping the amount of carbohydrate for each meal including snack everyday is the key. The types of carbohydrate may vary from day to day.

Choice B: Carbohydrate Counting Meal Plan

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Carbohydrate counting involves giving a matching dose of medication with the grams of carbohydrate taken daily. One carbohydrate serving is equal to 15 grams of carbohydrate. People with diabetes can get help from a dietitian to figure out the counting plan that meets the specific needs. A common plan for an adult normally consists of three to four carbohydrate choices for main meals and one to two for snacks. This meal plan is most useful for people who take multiple daily injections of insulin because it allows greater freedom and flexibility in food choices.

The formula for Insulin to carbohydrate ratio is 1:15. For example, 1 unit of rapid acting insulin would be given for each 15 grams carbohydrate eaten. If the meal consists of 60 grams of carbohydrates, 4 units of insulin would need to be given.

Choice C : Exchange Meal Plan (most commonly used)

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The Exchange System classify foods into three broad groups namely carbohydrate, meat and fat listing items which contain similar macronutrient composition. This equality allows the exchange of food on each list making it easier for patients to use as reference.  Most vegetables can be considered free foods if their energy contribution is minimal when eaten in moderation.

Carbohydrate Exchange List

  1. Cereals, grain products and starchy vegetables

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Each item contains 15g carbohydrate, 2g protein, 0.5g fat and 75kCal

1 cup is equivalent to 200 ml

1 tablespoon is equivalent to 2 teaspoons

2. Fruits

Each item contains 15g carbohydrate and 60kCal

3. Milk

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This food contains varying amount of carbohydrate, fat and protein depending on which type of milk.

Self-monitoring

Image Source: Diabetes Health Page

Despite being on treatment, it is estimated that over 30% patients DO NOT achieve good glucose pressure control despite being on medication. As such, healthcare practitioners also recommend lifestyle modification which includes 30-60 minutes of exercise daily (click and read article “How Much Should We Exercise Daily”) and self-monitoring. Do consult and connect with your healthcare practitioners such as your doctor, dietician or fitness trainers.

While at home, check your blood glucose regularly and take charge of your health. Do self-monitor your weight and blood sugar on TELEME TrackME Health Tracker mobile app.

References: Malaysians’ Dietitian Association. 2005. Medical nutrition therapy guidelines for Type 2 Diabetes. Nutrition Recommendations and Interventions for Diabetes”. American Diabetes Association. My Health.

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Diet for Diabetes

Diet for Diabetes

Click below to watch video on Diabetic Food List

A diabetic meal plan is a healthy eating plan which consists of balance nutrition in the right amount of calorie requirement and the right amount of food types.

The aim of a diabetic meal plan is to help people with diabetes attain quality of life similar to healthy people by:

  • making it easier to achieve blood glucose control
  • reducing dependency on more diabetic medication or insulin injections
  • reducing the risk of complications or hospital admission associated with diabetes
  • achieving the same lifespan as normal individuals

Why is diabetic control important?

Image Source: QDT

Diabetic control is important to prevent the following common complications.

  • Peripheral vascular disease of the lower limbs causing ulcers and gangrene of the toes and feet
  • Peripheral neuropathy causing numbness and tingling sensation of the toes and fingers
  • Blindness due to diabetic retinopathy causing bleeding into the eye. Diabetes is most common cause of blindness in young adults
  • Kidney failure. Diabetes is the most common reason why patients are on dialysis
  • Heart disease
  • Stroke

Why is body weight important in the control of diabetes?

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Being overweight predisposes you to developing diabetes as well as making it harder for you to achieve good diabetic control because

  • Fat makes it difficult for insulin to facilitate glucose to get into the muscle efficiently and as a result the glucose remains unused in high levels in the blood stream
  • The pancreas then has to work harder to produce more insulin resulting in organ failure after 20-30 years of poor diabetic control

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Losing as little as 5-10% of your weight can reduce your risk of developing diabetes.

What is an ideal Diabetic Meal Plan?

Food is the major influence on blood sugar levels in people with diabetes and as such patients must pay attention to the food components (particularly the carbohydrates), amount eaten and timing of each meal every day. Choose foods with lower Glycemic Index (GI) as these foods do not give you a sudden surge in blood glucose after eating.

Image Source: Healthline

GI is a ranking of carbohydrates on a scale from 0 to 100 according to the extent to which they raise blood sugar (glucose) levels after eating. Foods with a high GI are those which are rapidly digested and absorbed resulting in big surge in blood sugar levels immediately after a meal. Low GI carbohydrates produce smaller fluctuations and is therefore ideal for diabetic patients.

Examples of Glycemic Index of some common foods

The objective of all diabetic meal plans is to achieve better control of blood sugar levels and needs to be customised with special consideration for the Type 1 (insulin dependent diabetes) Type 2 (non-insulin dependent diabetes) and diabetes during pregnancy.

There is no one perfect meal plan and each plan has to be on trial basis and evaluated and adjusted as necessary. A good diabetic meal plan is one which can help patients manage their blood glucose at normal level AND allow them to enjoy their food.

Self-monitoring

Image Source: Diabetes Health Page

Despite being on treatment, it is estimated that over 30% patients DO NOT achieve good glucose pressure control despite being on medication. As such, healthcare practitioners also recommend lifestyle modification which includes 30-60 minutes of exercise daily (click and read article “How Much Should We Exercise Daily”) and self-monitoring. Do consult and connect with your healthcare practitioners such as your doctor, dietician or fitness trainers.

While at home, check your blood glucose regularly and take charge of your health. Do self-monitor your weight and blood sugar on TELEME TrackME Health Tracker mobile app.

References: Malaysians’ Dietitian Association. 2005. Medical nutrition therapy guidelines for Type 2 Diabetes. “Nutrition Recommendations and Interventions for Diabetes”. American Diabetes Association. My Health.

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Diet for Hypertension

Diet for Hypertension

Click to watch Stop Hypertension with the DASH diet

The healthy DASH (Dietary Approaches to Stop Hypertension) diet plan was developed to lower blood pressure without medication in research sponsored by the US National Institutes of Health.  Blood pressure is necessary to make our blood flow around the body to supply oxygen and nutrients to the muscles and vital organs. However, when the blood pressure gets too high, the heart has to pump harder and small blood vessels in the brain may burst causing heart failure and strokes respectively.

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What people do not realise is that high blood pressure is a ‘silent killer’ because in the beginning there is no symptoms until it is too late. That is why health practitioners keep advising patients to self-monitor their blood pressure regularly and eat well to maintain a healthy lifestyle. Do refer to how article ‘What is hypertension’.

Classification of Elevated Blood Pressure

The DASH diet recommends correct portion size and emphasizes on fruits, vegetables, low fat or non-fat dairy. The plan follows US guidelines for lower sodium content, along with vitamins and minerals (such as potassium, calcium and magnesium). In addition to lowering blood pressure, the DASH eating plan helps lower cholesterol and makes it easy to lose weight.

Image Source: Pexels

Successful adoption of any new diet is about gradual change. If you now eat only one or two servings of fruits or vegetables a day, try to add a serving at lunch and one at dinner. Try to avoid canned or dried fruits as they have added sugar. Rather than switching to all whole grains, start by making one or two of your grain servings whole grains.

Take charge of how much you eat by visualising your food portions for ONE SERVING

Reduce salt in your diet

  • Sodium is salt in restricted to (note that 1 teaspoon of salt has 2,325 mg sodium)
  • Standard DASH diet (2,300 mg sodium per day which is equivalent to 1 teaspoon salt)
  • Lower sodium DASH diet (< 1,500 mg sodium per day which is equivalent to 2/3 teaspoon salt)

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The low sodium DASH diet reduced blood pressure by average of 11 mmHg in patients with hypertension while normal people reduced by 3 mmHg.  It has been shown that the diet reduces the risk of stroke (by 29%) and heart disease (by 20%) as well as diabetes to a lesser extent.

Add exercise into your diet plan

The diet plan should also be supplemented by exercise.  Just 30 minutes of brisk walking a day for 5 days a week can reduce your blood pressure by around 13 and 18 mmHg in systolic and diastolic pressure respectively.

Click to read our article on ‘How much should we exercise daily’

References: Dash Diet, Mayo Clinic, Heart and Stroke, Heart

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