THE POST TRAUMATIC STREES DISORDER

Definition of the Post Traumatic Stress Disorder (PTSD)

At least 1/3 individuals who have been exposed to traumatic events develop long term problems. These problems (unexplained somatic complaints, anxiety, depeated consultations.

A traumatic event could be natural disasters (earthquake, hurricane, or rape, war or armed conflict. A traumatic event breaks off a normal life. It is extremely powerful, potentially harmful and outside the scope of the normal life events. These events could be episodic of repetitive, those are so everwhelming that one's basic consepts of safety, security, and basic turst, moral, ethnics and future perspective are shattered. The prevalence of mass traumatisation is often associated with cycles of violence.

A normal reaction or coping prosess is necessary to integrate the traumatic experience. During the coping process both mental and physical traumatic stress symptoms are prevalent. Although these symptoms are a part of a normal reaction to abnormal events the victims perceived them as threatening. The healing (or coping) process is negatively influenced by the contex of disruption.

Intensity and Frequency
If healing or integration of the traumatic event fails (for example, in the case of repetition of the event), a post trumatic stress disorders or other psychopathology (mood, anxiety, behavioral disorders and psychosis) may develop.

PTSD includes both psychological and physical symptoms that persist more than 1 month after the traumatic event. Otherwise, it will be an acute stress disorder, relatively normal after a traumatic event.

Although a great similaity predominates between the signs of traumatic stress and PTSD there is an essential difference in intensity and frequency. People suffering from PTSD are stuck in their symptoms, while the signs of traumatic stress are still considered as a "normal reaction to abnormal circumstances".

The person's respone currently involved intense fea, helplessness or horror. In children, they may express that bay disorganized or agitated behavior.

The are three groups of Symptoms Intruction or recurent distressing recollection

• Intrusive images or thoughts linked to the traumatic event despite efforts to block them out. In young children, repetitive play may occur in which themes or aspects of the truma are expressed.
• Recurrent distressing dreams linked to the traumatic event or nightmares. In children, there may be frightening dreams without recognized content.
• Flashback episodes during which the patient feels as he relives part of the traumatic event. In young children, trauma-specific reenactment may occur.

Avoidance

• The patient tries to avoid everything that might be associated with the trauma (places, situations, people that arouse recollections of the trauma), avoidance of conversations, feelings or thoughts related to the trauma
• Inability to recall an improtant aspect of the trauma
  
• Having thoughts about the trauma : alcohol, psychotropic drugs or toxic drugs may be used for this purpose.

Increased arousal

• Anxiety
• Insomnia, difficulty falling or staying asleep (these symptoms are important because if the patient doest't sleep well, he will spend his time to think on the traumatic event and his thoughts won't help him to sleep, so it may risk to fall in an infernal circle, with a body and mind tiredness)
• Exaggerated startle response, panic attacks, hypervigilance
  
• Sometimes hypertension, sweating, trembling tachycardia, headache etc.

Other Symptoms Behavioral

• Avoidance of social and family relationships (feeling of detachment or estrangement from others).
• Markedly diminished interest and participation in ususal activities.
• Drugs and alcohol use.

Affective

• Sadness, hopelessness, apathy
• Irritability, difficulty controlling emotions, outbursts of anger.
• Restricted range of affect (unable to have loving feelings)
• Feelings of misunderstood
• Sense of foreshortened future.

Sources : WHO, Health Massenger, http://nlm.nih.gov, MsF-Holland guideline

DIARRHEA AND DEHYDRATION

Diarrhea is an infectious disease characteriszed by an abnormal liquidity and frequency (3 times or mor in a day) of fecal discharges, causing 18% of the deaths that occurred among under-fives in Indonesia in 2005.

Causes
Diarrhea is caused by infections of illnesses that either lead to excess production of fluids or prevent absorption of fluids, due to bacteria (E. coli, Shigella, Salmonella, Vibrio virus, Adenovirus) or parasite (Ameba, Giardia lambli). It can also be caused by :

• Lactose intolerance,
• Carbohydrate intolerance,
• Carbohydrate, fat, and protein malabsorpstion,
• Food poisoning by chemistry substances poison, toxin microorganism, Clostridium perfringens, Staphylococcus,
• Immunedericiency.

Complications and prevention
Complications to diarrhea may occur : dehydration, disturbance of bases acid balances, disturbance of electrolyte balance, nutrition disorder, and anemia.

Proper hygiene and food handling techniques can prevent many cases of diarrhea. the most important action is to prevent the complications of dehydration, a loss of water and salts that are essential for normal body function.

Therapy A : Diarrhea without dehydration (to treat the diarrhea at home)

1. Give the child more liquid than usual to prevent dehydration: use recommeded home's liquid such as Oral Rehydration Solution (ORS), liquid food (soup, thick water) until the child's diarrhea stpos. For the baby under 6 months is better to give ORS and cooked water than liquefy food.
2. Feed the child to prevent under nutrition: continue breastfeeding (breastfeeding) or milk as usual. For children over 6 months give adequate feeding: Porridge or other flours mixture, if possible mixed with vegetables, meet or fish. Sore fresh fruit or soft banana to increase kalium. Fresh food, cook and soft it. Encourage the child to eat at least 6 times/day. Give the same food after the diarrhea stopped, and give additional food every day for 2 weeks.
3. Bring the child to the health facility if the child do not get better in 3 days or suffer: Pass stool is diluted and frequently. Repeated Vomitig. Very thirsty, Eat or drink a little. Fever. Bloody stools

Therapy B : diarrhea with mild to medium dehydration
The amount of ORS given in the first 3 hours = patient's weight (kgs) x 75 mL or if the weight is unknown : Age (year) <> 5 give ORS (mL) 1200, Adult give ORS (mL) 2400.

• Give more ORS if the child wants to. Show the ways to give it : one tea spoon in every 1 - 2 minutes to the children <2>
• Encourage the mother to continue breastfeeding.
  
• For the baby <6>
• Check time to time if there is a problem.
• If the children vomit, wait until 10 minutes and than continue to give ORS, but slowly example one spoon in every 3-4 minutes.
• If child's eyelid is swollen, stop to give the ORS and give the cooked water or breast milk. Give ORS accordance to plan therapy A if the swollen done.

After 3 - 4 hours, rexam the children by using examination draft, then choose plan therapy A, B, or C to continue therapy. If the signs still show mild/medium dehydration, repeat the plan therapy B but offer food, milk, and sore fruit as plan therapy A.

Glossary
Acute diarrhea : less than 2 weeks
Persistent d : diarrhea lasting more than 2 weeks.
Dysenteric d : diarrhea with muccous and bloddy stools
Choleraic d : acute diarrhea with serous stools, acampained by circulatory.
Collapse d : thus resembling cholera.

Good To Know
Gelatin water may be subtituted for electrolyte replacement solutions if an ORS is unavailable it is made by diluting a 3 oz package in a quart of water or by adding one-fourth teaspoon of salt and a tablespoon of sugar to a print of water.

Therapy C : diarrhea with severe dehydration
Start to give IV liquid soon. If the patient can drink give ORS when IV liquid is started. Give 100 mL/kg RL/NaCl, divides as follows : Age : Baby<1>

Exam again the patient in every 1 -2 hours. if no sign of rehydration make fast IV drops.

Also give ORS (5mL/kg/hour) if the patient can drink, usually after 3 - 4 hours (baby) or 1 - 2 hours (child), after 6 hours (baby) or 3 hours (child). Exam again the patient by using examination table. then plan therapy as necessary.

Send the patient for the IV therapy

If the patient can drink, provide ORS to the mother and show how to give it during travel

Start rehydration per oral with ORS. Give 20 mL/kgbb/hours for 6 hours (total 120 mL/kgbb)

Exam the patient every 1 -2 hours

If vomiting or the stomach puffing give the liquid slowly

If no sign of rehydration within 3 hours, refer the patinet to IV therapy

Afer 6 hours exam again the patient and give a plan.

Sources : General Coordinator, Zul habibi, Atjeh Student's Of health Orgnization ASHO, Health Massenger

HYPOSPADIAS

Hypospadias is a development anomaly in the male in which the urinary tract opening, or urethral meatus, opens the underside of the penis or on the perineum.

Etiology

The development of the penis place in early stages of pregnacy by the formation of the urinary channel and foeskin thanks to the stimulation of male hormones, various problems with hormone action may result in the congenital condition called hypospadias. in few cases, the cause of hypospadia in genetic.

Symptoms

Hypospadias is diagnosed most often during the initial newborn physical examination observing the urethral opening in a wrong position, combined in some cases with other symptoms :

• Foreskin incompletely developed resulting in a dorsal hood (tip of the penis exposed)
• penis curvature (chordee)
• undescended tested

If left untreated, hypospadias can lead to an abnormal direction of the urine stream, abnormal appearance of the penis, infertility if the defect is located far enough away from the tip of the penis, and an inability to have sexual intercourse in cases involving chordee.

Diagnosis
Hypospadias is classified based on where tha urethral meatus is located

Therapy

The degree of hypospaidias and the extend of penile curvature will determine the necessity of a surgical intervention.

The surgery aims to create a normal straight penis with a urinary channel that ends at the tip of the head of the penis. the operation usually involves four steps : straightenig the shaft; creating the channel; positioning the urethral opening in the head and either circumcising or reconstructing the foreskin

Occasionally, when the opening is proximal, tratment with the male hormone testoterone previous to surgery may be recommended. Males who have hypospadias located within or near the scrotum should also have a procedure called a voiding cystogram to rule out additional urinary tract anomalies.

The recommended age of surgical repair is between four and 12 months. this age is ideal for many reasons including the size of the penis and the slow rate of growth of the penis.

Children should not be circumsiced because the foreskin if often essential in hypospadias repair surgery.

Prognosis
After hypospadias repair the penis appears normal and functions normally, very few children experience postoperative complications (woud infections, unexpected opening near the repair site)

Possible forms of hypospadias :

1. Glandular / Distal
2. Midle penile
3. Pen scrotal
4. Perinea/proximal

Sources : RSU Zainoel Abidin, Dr. Dahril SpU. Health Massenger

AVIAN INFLUENZA

Avian Influenza : Getting the disease under control

With a death toll from the virulent H5N1 strain of bird flu of 55, Indonesia has the world's higherst number of human deaths. The country has become the focus of the fight against the virus. Most of the infections have been contracted from domestic fowl. The World Health Organization fears the virus could mutate a form that easily spreads among humans, sparking a global epidemic.

Prevention of Avian Influenza Infection Costumer of chicken and chicken products :

• Chicken meats and eggs in the market are safe but they be throughly cooked. Meat should be throughly cooked untill it is no longer pink.
• Do not eat half cooked meat (chicken, duck etc)
• Do not eat raw eggs or soft-boiled eggs.

Food handlers and people who prepare food for household comsumtion:

• Don't buy chicken meat that has dark, bruised or hemorrhagic spots.
• Don't buy unusually cheap chicken meat ( as this may suggest that the animal was sick before slaughter)
• Don't buy eggs that have cracked shells or have dirt, feces or feathers on them. wash eggs thoroughly before cooking.
• Don't use dirty hand to touch the nouse, eyes, or mouth. Wash hands frequently, especially after handling chicken meat, duck meat, offal and eggs.
• Use separate chopping boards for meats, vegetable, cooked and raw food.

Sources : Avian Influenza Team, WHO Indonesia, Health Massenger,

DOWN SYNDROME

Down Syndrome, or trisomy 21, is a common genetic variation characterized by the presence of one or part of an extra chromosome 21 in an individual's genetic identify or karyotipe.

This chromosomal rearrangement usually causes variation in mental abilities and delays in behavioural and physical development and is one of the leading clinical causes of cognitive delay. the women's age appears to be the most important risk factor responsible for this genetic disorder.

Symptoms And Development
Though being a chromosomal disorder, a set of physical characteristics are usually identified on babies with down syndrome at birth: overly quiet, less responsive, with weak and floppy muscles.

Main Symptoms of Down Syndrome
While develoving, some physical features may be observed on children with trisomy 21:

• flat appearing face and small head
• slanting eyelids
• depressed nasal bridge
• small ears
• small skin folds at the inner corner or the eyes
• small mouth
• decreased muscle tone
• loose ligaments
• short wide hands with small fingers and a line across the palm (50%), often with a gap between the first and second toes
• small feed

The physical features observe in children with Down Syndrome (and there are many more than described above) generally do not couse ani disability. nevertheless, children with down syndrome ususally present severe mental retardation and their motor development is slow instead of walking by 12 to 14 months as other children do, they might learn to walk between 15 to 36 months and language development is also maredly delayed

Health Conserns usually oberserved in individuals with Down Syndrome
Children with Down Syndrome need the same medical care as any other children. The paediatrician or family physician should provide general health mainenance, immunizations; attend to medical emergencies, and offer support and couselling to the family. but as other types of defects often accompany Down Syndrome, there are nevertherless situations when special attention and appropriate tratment is necessary.

1. A significant propotion of children with Down Syndrome have Hearing Deficits. therefore, audiologic assessments at an early age and follow-up hearing tests are indicated. if there is a significant hearing loss, the child should be seen by an otorhinolaryngologist (nose, ear and throat specialist).
2. Children with Down Syndrome may have congenital heart disease. Many of these children will have to undergo cardiac surgery and often will need long term care by a paediatric cardiologist.
3. Intestinal abnomalities also occur at a higher frequency in children with Down Syndrome. For example, a blockage of the esophagus (food pipe), duodenum (small bowel), and at the anus are not uncommon. these may need to be surgically corectd at once in order to have a normal functioning intestinal tract.
4. Children with Down Syndrome often have more eye problems then other children who do not have this chromosome disorder. For example, some infants with trisomy 21 have cataracts. They need to be removed surgically. Other eye proglems such as trabismus (cross eye), near-sightedness, far-sightedness and other eye conditions are also frequently observed
5. Another concern related to nutritional aspects. Some children with Down syndrome, in particular those with severe heart disease often fail to thrive in infancy. on the other hand, obesity is often noted during adolescence and early adulthood. these conditions can be prevented by providing appropriate nutritional counseling and anticipatory dietary guidance.
6. Thyroid dysfunctions are more common in children with Down syndrome. Hypothyroidism for example is important to identify early since it may comprpmise normal central nervous system functioning.
7. Skeletal problems have also been noted at a higher frequency in children with Down syndrome, including kneecap subluxation (incomplete or partial dislocation), hip dislocation, and atlantoaxial instability. the latter condition occurs when the first two bones are not well aligned because of the presence of loose ligaments.
8. Other important medical aspects in Down syndrome, including immunlogic concerns, leukemia, Alzheimer disease, seizure disorders, sleep apnea and skin disorders, may require the attention of specialists in their respective fields.

Stimulation services and vocational opportunities
Researched have shown that early intervention, environmental enrichment, and assistance to teh families will result in progress that is usually not archieved by those infants who have not by such educational and stimulating experiences.

Children with Down syndrome, like all children, can benefit from sensory stimulation, specific exercises involving gross and fine motor activities, and instruction in cognitive development. Also, preschool plys and important role in the young child's life since exploring the environment beyond the home enables the child to participate in a broader world.

Experiences provided in school assist the child in obtaining a feeling of self-respect and enjoyment and give an opporunity to engage him in sharing relationships with others.
Health and educational services have an important role in stimulating development and preventing secondary effects. Doctors, physioterapists, occupational therapist, speech therapists, psychologists, nurses and educators should work alongside with the family and the child in order tob able to maximize the capacities of the child.


Sources : Dr. Andrew Carroll, University of Alabama at Birmingham, Health Messenger.

INTESTINAL WORMS INFECTONS

Intestinal worm infection is a tropical and sub tropical disease caused by a lack of hygiene and healthy behavior, most of the time transmitted by touching contaminated or eating uncooked food grown in contaminated soil or irragated with inadequately trated wastewater.

Definition
The WHO defines the Ascarisasis, the most common human parasitic infections, as "an infection of the small intestine caused by Ascaris lumbricoides, a large roundworm. The eggs of the worm are found in soil contaminated by human feaces or in uncooked food contaminated by soil containing eggs of the worm. A person (and especially a child) becames in fected after accindentally swallowing the eggs. The eggs hatch into larvae within the person's intestine. The larvae pentrate the intestine wall and reach the lungs through the blood stream. in the intestines, the larvae develop into adult worms. the female adult worm which can grow to over 30 cm in length, lays eggs that are then passed into the feaces. if soil is polluted with human or animal feaces containing eggs the cycle begins again. eggs develop in the soil and become infective after 2-3 weeks, but can remain infective for several months or years.

Kind Of Disease :

1. Ascaris lumbricoides (roundworm), high prevalence, especially among children, frequency 60 - 70%, worm size 10 - 35 cm, the worm can produce roe around 100000 - 200000/day, a big worm in the kidney sucks 0.14 g carbohydrate/day and disturb absorption of vitamin A.
2. Necator Americanus and Ancylostoma deudenale (hookworm), high prevalence especially in planantation area, land loose. Relate to the using of the faeces as fertilizer and the habit of not using slipper/shoes, size around 1 cm, giving roe 10.000 granules/day. A big worm sucks 0,1-0,2 mL blood/day.
3. Trichuris trichiura(whipworm), frequency around 30-90%, the spreading is related to contamination between the soil and faeces, size 4 - 5 cm, a worm can produce 3000-10000 roes/day. do not pass lung cycle, big worm live especially in the ascending colon, sucking food subsance and 0.005 mL blood/day
4. Enterobius Vermicularis (pincourm), Transmission can occur in a family or a group staying in the same environment (dormitory house), size 2 - 13 mm. worm produce 11.000-15.000 roes/day in perianal area.

Symptoms
Several symptoms can be noticed :

• Degestive symptoms ; stomach ache, nausea, vomit, low weight, fever, darrrhea, or constipation. Diarrhea can sometimes be combined with dysentery syndrome and ractum polactus. The pinworm can give pruritus ani especially at night, enuresis, and irritability. A chronic infection can also contrubute to food allergy. a worum living in the kidney can also cause a reduction of nutritive substances (macronutrient and micronutrient) leading to malnutrition problems, less appetite, absropstion difficulties.
• Respiratory symptoms; cough, wheezing and difficulty in breathing, or fever.
• Urinary tract symptoms: kidney obstruction (roundworm)
• Metabolic symptoms: blood artery wall iritation (whipworm). iron deficiency (leading to anaemia)
• Immunological suppression
• Genarally lagging development (but mostly physical)

Interventions
Health education providing the following massages reduces the number of infected people :

• Avoid contact with soil that may be contaminated with human faeces;
• Wash hands with soap and water before handling food;
• Wash, peel or cook all raw vegetables and fruits;
• Protect food from soil and wash or reheat any food that falls on the floor.

Treatment
The tratment can be conducted publicly or personally, with pyrantel pamoat, membendazol, or albendazole. Infected individuals should be treated to reduce total of 1,913 (93%) of children aged 2 - 5 years in two districts of Aceh were given OPV + albendazole (400mg)

Sources : WHO, Medical Editor,

CLEFT LIP AND PALATE

A cleft lip and or palate is a birth defect (congenital) generally of the upper part of the mouth. A cleft lip creates an opening in the upper lip between the mouth and nose and a cleft palate occurs when the roof of the mouth has not joined completely.
In sumatra, 1 of 300 children is born with cleft lip and or palate. children of Sumatra, a NGO created in 2002, has coordinated until now 60 operations in hospital and rehabilitation units in Medan, beneficiating from the special intervention of a western plastic surgeon for most severe cleft lip and or palate cases. In September 2007, 42 operations have been realized.

Causes
Causes of cleft lip and or palate are not well identified; nevertherless a combination of genetic and environmental factors may favor appearance of this congenital defect:

• Family history of facial clefts
• Alcohol and drugs abuse during first weeks of pregnancy.
• Vitamins lack (especially folic acid) during the first week of pregnancy
• Mothers with diabetes

Diagnosis
Because clefting causes specific physical manifestastions, it is to diagnose. for an accurate diagnosis and classification, check :

• The harelip localis status in detail,
• The nature of the clefting; lip, palate or both
• Cleft extensivities; complete (a cleft extended through the entire affected mouth structure), gnatho (gums), or incomplete (limited disruption, ususally the gnatho is still complete),
• Cleft location: unilateral (one side) or bilateral (both side),
• Alveolar and gums segment; is there a gap or not? is the gap wide or narrow? Does it collapse or not?

Clefts may occur alone or with other abnormalities (hidden or obvious) in the saliva glands, genital area, fingers and extremitas and may be combined with mental retardation, or hearth and other facial anomalies, so newborns with clefts should be carefully examined by a specialized physician soon after birth.

Cleft palate's patient normally also have tuba Eustachian function disorder and are more likely to suffer from otitis media which can have repercussions on earring functions and speaking learning process. In such case, a consultation with THT specialit (otolaryngologist) is needed.

Treatment
Due to the physical appearence modification, untreated cleft lip (in most cases because of treatment costs) can have repercussion on children self-esteem increased by social acceptance dificulties, generating educational problems.

A cleft lip and or palate can be repaired with corrective surgery :
Labioplasty or cheiloplasty is the plastic surgery of the lip. The recomended age for the surgery follow the 10 s rule :

• Age > 10 weeks (3 months)
• Weight > 10 pounds (5 kg)
• Hb > 10 g/dl

Process :
The edges of the cleft between the lip and nose are cut. The bottom of the nostril is formed with suture. The upper part of the lip tissue is closed and the stitches are extended down to close entirely.

Palatoplaty (platic reconstruction of the palate) is ideally practiced between 18-24 months on healthy children and before speech abilities are developed. to prevent speech dysfunction it is recommended to consult a speech therapist 3 to 6 months after palatoplaty.

Sources : WHO, Young, Greg, M. D (1998). Cleft Lip and Palate January 28 1998, UTMB Dept. of Otolaryngology Grand Rounds, RSU Zainoel Abidin, Plastic surgery specialist, Dr. BJ. Bismedi.