Ask Your Doctor 200 (10.08.2017)

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1. Z.A., Mangalore

*I am 29 years of age. I had recently tested my blood for sugar levels, liver and kidney functions. The results have shown that the uric acid level is 7.1mg per dl. Also the triglycerides are 331mg per dl. All other values are in normal range. Please note, my father at present too has a high uric acid levels. Please advise on this and let me what foods are good to lower the levels. Will this lead to complications in future?

** Both the problems of hyperuricemia and hyperlipidemia can be controlled to major extent by diet.
Uric acid is produced in our body and it normally dissolves in the blood, processes through the kidney, and leaves the body in the urine. If the body makes extra uric acid, or if the kidneys cannot clear enough of it, then uric acid levels in the blood become too high, a condition known as hyperuricemia. Uric acid in the blood is saturated at 6.4-6.8 mg/dL at ambient conditions, with the upper limit of solubility placed at 7 mg/dL. If it exceeds this level, the condition is termed as hyperuricemia. Hyperuricemia is not a disease and may not cause problems, but if it continues for a long time and conditions in the body are right, crystals may form and cause gout and kidney stones. Kidney stones are more dangerous than gout. Gout is a painful disease with severe pain and swelling most commonly affects the joint of great toe and at times in other joints. Uric acid crystals deposited in the joints can cause pain, swelling, stiffness, deformity, and impair movement. Uric acid crystals deposited in the kidneys can become large stones. These stones are very painful and can cause permanent kidney damage if not treated in time.

Uric acid comes from the breakdown of purines, naturally-occurring chemicals that are found in both our diets and our bodies. Foods and drinks that contribute most to hyperuricemia and gout include: red meat, organ meat, seafood, beer, liquor, and sugar-sweetened items, especially with high fructose syrup. Health problems such as obesity, high blood pressure, high blood sugar and high cholesterol may also lead to increased uric acid. Other causes of hyperuricemia include kidney disease, exposure to lead, hypothyroidism, severe illness or stress, and extreme physical exertion.

Most patients with asymptomatic hyperuricemia never develop gout or stones. Pharmacologic treatment for asymptomatic hyperuricemia carries some risk, is not considered beneficial or cost-effective, and generally is not recommended. However, these people can be advised on lifestyle changes such as changes in diet, reduction in alcohol intake, and exercise, which may lower uric acid levels. It should be remembered that having a high uric acid level is not a disease or a condition that necessarily needs to be treated or searched for in the absence of other symptoms. But if there is an attack of gout or have a certain type of kidney stone, then treatment may be needed.

Triglycerides are a type of fat (lipid) found in the human blood. The body converts any excess calories that doesn't need to use right away into triglycerides. The triglycerides are stored in the fat cells. Later, hormones release triglycerides for energy between meals. If one regularly eats more calories than the body burns, particularly "easy" calories like carbohydrates and fats, then one may have high triglycerides (hypertriglyceridemia).

High triglycerides are often a sign of other conditions that increase the risk of heart disease and stroke as well, including obesity and metabolic syndrome — a group of conditions that includes too much fat around the waist, high blood pressure, high triglycerides, high blood sugar and abnormal cholesterol levels. Sometimes high triglycerides are a sign of poorly controlled type 2 diabetes, low levels of thyroid hormones (hypothyroidism), liver or kidney disease, or rare genetic conditions that affect how the body converts fat to energy. It is an indicator of bad cardiac health and triglycerides should be brought under control. Healthy life style, narrated below might help to reduce both elevated uric acid and triglycerides; however it is recommended to consult physician for further assessment and medication.

Healthy lifestyle choices that might help to reduce uric acid as well as high triglycerides:

• Reduce body weight: If one is obese or overweight, reducing weight has lot of beneficial influence on several other health problems including hyperuricemia and hyperlipidemia. Reducing calories and regular exercises help in reducing body weight.

• Limit the calories: Extra calories are converted to triglycerides and stored as fat. Reducing the calories will reduce triglycerides. One should know the calorie needs of his body and should try to restrict the calorie intake to it, at least roughly.

• Avoid sugary and refined foods: Simple carbohydrates, such as sugar and foods made with white flour can increase triglycerides. Eat more fruits, vegetables and whole grains, which provide complex carbohydrates. Avoid foods such as white bread, cakes, candy, sugar-sweetened beverages and products with high-fructose corn syrup. This also helps to reduce uric acid.

• Choose healthier foods. Better to avoid saturated fat found in meats and opt for healthier monounsaturated fat found in plants, such as coconut oil, sunflower oil or similar other oils. Remember excess oil, even if it is from plants is not good for health. Avoid meats such as liver, kidney and sweetbreads, which have high purine levels and contribute to high blood levels of uric acid. Avoid the following types of seafood, which are higher in purines than others: herring, sardines, mussels, scallops, trout, haddock, mackerel and tuna.

• Water: An increase in water consumption has been linked to fewer gout attacks. Aim for eight to 16 glasses of fluids a day with at least half of that as water. A glass is 8 ounces (237 milliliters).People with cardiac problems may have to discuss this with their doctor.

• Stop or reduce alcohol: Alcohol and sugar has a particularly potent effect on triglycerides as well as on uric acid. Even small amounts of alcohol consumption can raise triglyceride levels.

• Exercise regularly. Aim for at least 30 minutes of physical activity on most or all days of the week. Regular exercise can lower triglycerides and boost "good" cholesterol. Take a brisk daily walk, swim laps or join an exercise group.

2. S.B., Udupi.

*I am having problem of headack and I am allergic to most of the medicines. If I take medicines I get severe breathing problems,wheezing,itching, running nose, cough. I have also tried Ayurveda, Homiopethy without any relief. What may be done?

** You may consult an ENT surgeon and findout the cause of headache. You may also discuss with the doctor about your hypersensitivity to medicines. If the cause is known the headache may be avoided by treating the cause. Certain lifestyle changes can help to reduce the attacks of migraine type of headache. There are certain types of headache which cannot be cured and may require pain relievers. In such cases you may be advised to take certain other types of analgesics which do not belong to the group of non-steroidal anti-inflammatory drugs. You seem to be having severe type of hypersensitivity to non-steroidal anti-inflammatory group of drugs and they have to be avoided.

3. J D., Mumbai

*I am 33 years. I have been having physical union with my wife but still she is not being able to conceive ,could you please advise what might be the reason?

** Most of the couples who are not able to get a child in the initial periods of marriage are also normal and they fail to get the baby because they are not able to find out the exact dates on which their physical union can result in pregnancy. The problem of not getting the child should be approached step by step.

You may be aware of the fertile days in the menstrual cycle of the woman. These are the only days in which proper physical union can result in conception. The ‘mid-fertile day’ is 14th day prior of the next menstrual flow. This is the day on which ovum comes out of the ovary (day of ovulation) and if sperm unites with it, it will result in conception. The ovulation can differ slightly on either side. The unfertile ovum has only about 8 hours life and it should become fertile within that period. (In contrast the sperm can live up to 72 hours in female genital tract) That is, if a lady’s period (the day on which flow starts) is 30th of the month, and then 16th (30-14=16) is the mid fertile day. The couple should have physical union on mid fertile day, two days preceding and two days following the mid-fertile day. That is on all the 5 days from 14th to 18th. (This is also one of the ‘Natural Family Planning Methods’, where the couple is advised to avoid physical union on these 5 days to prevent the conception naturally). There are few other details like the position used for physical union, precautions after union etc. This is the natural method through the couple can try to get the child.

Even after trying through natural method for at least 6 months, if the couple fails to get the good news, and then an expert gynecologists may be consulted initially. Normally the man is tested first. The analysis of the semen after minimum of three days abstinence and collected properly is done. If there are any defects in semen analysis, the man has to be treated first. Mean while the woman also may be tested initially by simple tests like ultrasound scanning. Surgical tests are normally done at a later stage if required only. There are fertility clinics at many places, but it is advisable to be cautious to get their help. It is a fact that many of these centers do unnecessary and costly tests and they do not follow step by step approach to the problem of infertility.

4. N.M., Mumbai

*I am 27 years of age. My height is 6ft and weight is 65kgs. From the past 2 months am getting sever back pain and pain on the back side of neck. It really hurts me. Am a IT engineer. While sleeping I do not use pillow. But still my necks pains a lot. Could you please suggest what can be done.

** Most of the people who do not care of the posture while working on the computers are likely to get back ache or neck pain. This has to be addressed as early as possible because persistent bad posture can cause disk degeneration and can become a permanently nagging problem. Initially you may consult an orthopaedic surgeon and get yourself assessed . You may be advised some medication and physiotherapy. The physiotherapist can teach you proper exercises to build up the muscles of the neck and back.

Here are some basic tips about the posture while working on the computers:

Keep your head up: Focus on aligning your head and neck right above your shoulders; avoid straining forward. The monitor should be adjusted in such a way that the topmost line on the screen does not make an angle more than 20 degrees with the plane of your eyes. That means you should not strain your neck by looking up or too down while on the computer.

Quit squinting, straining and leaning forward: This is especially common when you use a laptop as your primary computer—you need to lean forward to reach keys or see the screen. Your torso should be about an arm’s length away from the monitor, which should be 2 to 3 inches above eye level The other way to solve the problem: attach a separate monitor and keyboard.

Chose a right chair : The chair that you use while working on the computer should be such that it allows your lower back to rest against a lumbar support. The chair can tilt back very slightly. Excessively reclining chairs cause more stress on the back.

Proper angle for knees and ankle : While sitting on the chair you should be able to keep your knees at 90 degrees, directly over your ankles; this will keep your spine comfortably upright. You should be able to keep your feet comfortably on the floor; they should not be hanging while you sit on the chair.

Don't cross your legs: Sitting cross-legged makes it difficult to keep your spine straight and shoulders squared, and you risk overstretching the muscles around the pelvis, upping your risk of varicose veins by interrupting blood flow. So uncross the legs and relax.

No more phone cradling : Pinning the phone between your shoulder and ear while you multitask is an instinctive move—and it strains the neck. Use a headset or speakerphone for any conversation that lasts more than five minutes.

Keep the mouse close: Ideally the mouse should be placed right next to the keyboard so that you don’t overreach or twist your shoulder, arm, or wrist when clicking.

Other than this there are certain exercises:

i Take breaks : Getting up at least once an hour—to go to the bathroom or just do some shoulder rolls—reduces pressure on spinal disks and boosts circulation.

ii. Stretch the shoulders: Roll the shoulders back and down, and square them over the hips. Do this exercise regularly. You may learn more about the exercises from physiotherapists.

5. N K C, Mangalore

*I am married and have two 2 small children. I have normal sex life. My problem is my penis is very small. I always wanted to increase the size. I read somewhere there is no medicine for that. Is that anything I can do to change the size. Please advice

** The size of the male organ can not be altered by any medications, local applications, exercises or even by plastic surgery. Men with small organ can perform as effectively as with the men having larger than average penis. Though there are many advertisers claiming the benefits, almost all of them are hoax.

The size of the penis is a common cause of worry in many of the young men. It's not difficult to find out about the size of the average male member - there are lots of surveys on the internet and in scientific journals, and one can easily work out the average size ranges. But how reliable are these figures? The answer seems to be - not very! When you ask men to measure their own penis, they consistently get longer results than when health professionals measure it! So, taking all the surveys, working out the average, and then adjusting the results in favor of those where measured by others the guys' penises, here are the most reliable figures: Average soft (flaccid) penis length = 3.3 inches (8.4 cm) Average erect length = 5.9 inches (15.0 cm).

In marital sexual relationship the size of the penis matters very little. Marital sexual act is not a mechanical union. There are lots of feelings that are involved and the size of the organ hardly matters for proper physical union. There is one more interesting thing is that most penises are very much the same size when erect. The man whose non-erect organ is smallish will usually achieve about 100 per cent increase in length during sexual excitement, while the man whose non-erect penis is on the largish size will probably only manage about a 75 per cent increase. In round figures, this means that the great majority of men measure between 15cm (6") and 18cm (7") in the erect position, with the average figure being about 16.5cm (6 ½").

6. K.B., Mangalore

*I am 48 years of age. My cholesterol level is on border line. My doctor suggested me to go for walking and avoid oily food. I am a pure vegeterian and non-alcoholic. Please suggest if I could take any medicines to lower cholesterol.

**Most of the people with raised cholesterol level are advised lifestyle changes to reduce the cholesterol. Lifestyle changes can help not only to reduce cholesterol, but also to improve overall health. (Certain guidelines are given in the answer to question no 1 in this update) For most of the people life style changes like a healthier diet and more exercise may prevent or treat unhealthy cholesterol levels. For others, medication may also be needed.

You may consult your doctor with your concerns. The doctor can assess your risk for a heart attack or stroke based on your cholesterol levels and other risk factors. From there, you can work with your doctor to develop a treatment and prevention plan that's right for you.

Various medications are used to lower blood cholesterol levels. Statins are recommended for most patients because they’re the only cholesterol-lowering drug class that’s been directly associated with reducing the risk of a heart attack or stroke. Your doctor may consider other medications too, especially if statins cause serious side effects or they don’t help you enough.

Guidelines recommend by American Heart Association that people in any of these four groups talk to their doctor about the risks and benefits of statin therapy:

• Adults 40-75 years of age with LDL (bad) cholesterol of 70-189 mg/dL and a 7.5 percent or higher risk for having a heart attack or stroke within 10 years.

• People with a history of a cardiovascular event (heart attack, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack, or coronary or other arterial revascularization).

• People 21 and older who have a very high level of LDL (bad) cholesterol (190 mg/dL or higher).

• People with diabetes and a LDL (bad) cholesterol level of 70-189 mg/dL who are 40 to 75 years old.
Some patients who do not fall into these categories may also benefit from statin therap

7. K.B., Mangalore

*During ultrasound examination, my prostate is 34 grams (Grade I Prostate) Is this a serious problem? Any treatment is requuired? Also reported as fatty liver? I am a non-alcoholic. Any treatment required?

** Prostate gland enlargement is a common condition as men get older. Also called benign prostatic hyperplasia (BPH), prostate gland enlargement can cause bothersome urinary symptoms. Untreated, prostate gland enlargement can block the flow of urine out of the bladder and cause bladder, urinary tract or kidney problems. There are several effective treatments for prostate gland enlargement, including medications, minimally invasive therapies and surgery. If you do not have symptoms like frequent or urgent need to urinate, increased frequency of urination at night (nocturia), difficulty starting urination ,weak urine stream or a stream that stops and starts or an inability to completely empty the bladder you need not take any medication.

Nonalcoholic fatty liver disease usually causes no signs and symptoms. Many people are reported with fatty liver in the ultrasound without any specific symptoms. Most of them do not develop any complication or illnes due to this. Normally nothing is required to be done. However you can consult your physician for proper assessment.

8. K.T., Kuwait

*I am 32 years of age, married for 07 years now. Having baby girl who is two years of age. My husband has lost interest in union after the baby birth. As soon as he goes to bed he falls sleep. Initially I thought he is tired of work, but it continued. In the past two years he was in mood maximum 10 to 12 times. What can I do? How to start conversation about this to him? Last week he told me that he have some red color marks which are burning on his private part. Candid ointment was applied He is not willing to show to doctor.( He is very shy, he says if he would rather die than showing his private parts to doctors.)

** Loss or reduction in sex drive in men is not common. When it happens it can be due to one or more causs. Psychological issues are the commonest cause. They include stress and anxiety from the strain of daily life, relationship or family problems, depression, and mental disorders are among the many factors that can affect sexual desire. Obesity, diabetes mellitus, hypelipidemia and certain medications also can lower sex desire. Low testosterone level is another common cause. You have to find a suitable occassion and discuss this with him and convince him to consult a specialist.

9. T.K., Kuwait

*My baby is two years of age. My baby falls sick most of the time. mainly with cold, cough and fever. Pediatrician says cause is baby sitting. (We cannot manage with ones salary, I can’t leave the job) She had fever in the last March and June. I came to know that antibiotics not good . My neighbor suggested me to take her to homeopathy doctor. Is it true that by consuming homeo medicines babies get immunity? They will not fall sick often if homeo medicines are given? If we start homeo medicine can we give allopathic medicine also? Whole life she has to get homeo medicines only?

** Some children seem to always have upper respiratory tract infections. They get one cold after another. Children start to get colds after about 6 months of age. Babies, toddlers, and preschoolers get about 7 or 8 colds a year. During the school-age years they average 5 or 6 colds a year. Teens finally reach an adult level of about 4 colds a year. In addition to colds, children can have diarrheal illnesses (with or without vomiting) 2 or 3 times per year. Some children tend to get high fevers with most of their colds or they have sensitive gastrointestinal (GI) tracts and develop diarrhea with most of their colds.

The main reason the child is getting all these infections is that he or she is being exposed to new viruses. There are at least 200 different cold viruses. The child's body will build up defenses (immunity) against these viruses when he or she is exposed to them. But this takes time. It takes many years to build up immunity to cold viruses. The child will be exposed more if he or she attends day care, play group, a church nursery, or a preschool. Older brothers and sisters may bring home a virus from school. Colds are more common in large families. The rate of colds triples in the winter when people spend more time crowded together indoors breathing recirculated air. Smoking in the home increases the child's susceptibility to colds, coughs, ear infections, sinus infections, croup, wheezing, and asthma.

If the child is over age 3 years, sneezes a lot, has a clear nasal discharge that lasts over a month and doesn't have a fever, the child may have an allergy. This is true especially if these symptoms occur during pollen season, the child probably has a nasal allergy (hay fever). Allergies are much easier to treat than frequent colds because medicines can help control symptoms.

Colds are not caused by poor diet or lack of vitamins. They are not caused by bad weather, air conditioners, or wet feet. Some parents worry that they have in some way neglected their child or done something wrong to cause frequent colds. Having all these colds is an unavoidable part of growing up. Colds can't be prevented. They help build up the child's immune system. Also, if the child gets a lot of ear infections, it doesn't mean that the child has a serious health problem. They mean only that the tubes in the ear aren't draining properly.

Many parents are worried that their child has some serious underlying disease because they get a lot of colds. A child with an immune system disease doesn't get any more colds than the average child. The difference is that a child with an immune problem will have trouble recovering from illness. They also will have 2 or more serious infections per year, such as pneumonia, sinus infections, draining lymph nodes, or boils. In addition, a child with a serious disease does not gain weight very well or look well between infections.

I hope it is clear to you now that your child does not require any treatment for repeated viral infections.

10. A.K., Bangalore

*I am 34 years of age, I am working in an airline company, I do not have smoking habits, but In my office my manager smokes minimum 2 packets a day, because of this smell I feel very bad and I am inhaling it. Will this cause any problem to my health?

** The effects of indirect tobacco smoking can be as bad as the direct smoking. Passive smoking, second hand smoking or environmental tobacco smokings are the terms that are used to describe the smoke that is exhaled by smokers or that burns from the end of a cigarette, pipe or cigar. Passive smoke is then involuntarily inhaled by non smokers. Passive smoke stays in the air for several hours after the smoker stops smoking.

There are numerous detrimental health effects of passive smoking. Many of the risks are similar to those associated with actual smoking a cigarette, pipe or cigar. Thousands of cancer related non smoker deaths and non smoker deaths from heart related issues can be linked to passive smoking.

Second hand smoke has been known to cause higher rates of lower respiratory infections, including bronchitis and pneumonia. Passive smoking also contributes to an increased amount of upper respiratory irritation and infections. Studies have also shown that passive smoking results in decreased lung function. This is especially true in children and infants, who tend to breathe quicker and have less control over their surroundings. Other than this passive smoking increases the possibilities of getting ear infection and asthma in children.

Several studies have found that passive smoking can be accountable for an increased risk of still births and spontaneous abortions than those who are not exposed to smoke.

The health effects of passive smoking, or second hand smoking, are undeniable. They are serious, debilitating and life threatening. Although it may be impossible to avoid all traces of passive smoking, it is certainly in everyone's best interest, especially those of children and women that are pregnant, that it be avoided as often as possible

11. S. S. Mangalore

*Myself and my partners were in relation but we both were wearing our inner garments. I have read that the sperms can transfers through cloths also. It means that I may get pregnant without having intercourse? We have problem in our family so I don't want to get pregnant now. But after reading all these articles I am really scared.

** I presume you are married; and if you are, then to prevent conception you have to follow the definite method of family planning. Avoiding sexual intercourse as a method of family planning can be dangerous for your mutual relationship. Discuss with your husband about a suitable method that can help you to perform the marital act but will prevent conception for some time. Using the contraceptive pills may be the ideal method if you do not want to conceive for a year or two. As a temporary method it is effective and safe.

Technically any form of heterosexual genital contact can result in conception. But the possibilities of conception when both of you were wearing the inner garments is rare. The semen has to enter into the vaginal opening and then only the sperms will travel inside the female genital tract. If the semen is dropped some where on the external genitalia (vulva), the sperms will not swim towards the vaginal opening and conception is unlikely.

12. M. P. Mumbai

* We have a son who is now two and half years of age. We are planning for a 2nd baby. Is it ok if we plan now? How many years gap should be there between two children?

** Now it is the ideal time for you to plan for the second child. The age gap between children is a matter of a personal choice, financial considerations and health concerns. The decision when to have your next child will also influence the relationships within the family. There is no perfect age gap between children that would work wonders because every family is unique.

Mother's age is one of the main factors that influence the choice of having another baby. Younger women may decide to wait longer before conceiving another baby, while those who had their first child in the age 35 and over may be more concerned about decreasing fertility and decide for smaller age gap between the children. A gap of at least two years between two childbirths is ideal. Early pregnancy, within six months after the first is a risk factor for such complications as premature delivery, low birth weights and others. And if the age gap between children is more than five years, these risks may become significant again.

Considering all aspects of health a gap of three years between two babies seems to be ideal. There are several reasons for that:

• A child younger than three years old feels special connection with his mother, when he cannot emotionally separate from her. If mother
switches her attention to another baby, her first child can experience certain difficulties, reflected in his psychological development.

• The bigger gap between children means there will be fewer conflicts between siblings. The older child is prepared to the arrival of the younger one, being more reasonable and understanding.

• The older child is rarely jealous of the new family member as he was fully cared for as toddler.

• Children older than three years show natural interest towards babies and may want to take part in baby's care.

The smaller age gap between children often is associated with more difficulties for a couple. It may take a lot of emotional, physical and financial resources for parents to care for two or more children especially in the early years. But it may also mean that parents will easier adapt to the demands of the new baby having the previous experience not so long ago.

There are certain advantages and disadvantages of smaller age gap between children. First of all, children closer in age will be a good companion to each other, can always entertain, play together and learn. But it may also mean more rivalry between children as they often may want the same things. The smaller child often spends more time with his or her sibling and less time with parents, which may delay his speech development. For a mother smaller age gap between children is often quite a difficult time. It can be hard time for a woman to care for the next child during pregnancy, especially if it is complicated. She may find it difficult to organize childcare of two small children, who have different schedules and thus she may experience stress.

13. J.P., Mangalore

*I am 26 years of age. Every night during the sleep my saliva comes out of mouth. I have been having this problem for many years. Is it normal? Whether there is any solution for this?

** Drooling, otherwise known as sialorrhea, is something that millions of people do in their sleep every night. During sleep our muscles relax and in certain stages of sleep (like during dreams) our skeletal muscles are near paralyzed state with the exception of the muscles of the eyes and the muscles of breathing. The mouth may open during these periods of sleep. This is usually related to body, neck, and head position. If the mouth is open during sleep, saliva may run out of the mouth (drool). This is normal and need to be treated.

There are certain sleep related disorders that may increase drooling. Some of these problems include acid reflux disease, seizures that occur during sleep, sleep behavioral abnormalities, and sinus disease that worsen when sleeping on the back.

There are no safe medicines that can reduce the production of saliva. A dentist or an oral surgeon can discuss these issues further.
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14. M.M. Mumbai

* Is there any chance of getting Hbs Ag (Hepatitis B) positive even after vaccination? I have taken three doses of vaccination and one booster dose. Does the vaccination gives life long protection or should I need to repeat once again?

**Hepatitis B vaccine, usually a three-dose series, is recommended for all children 0-18 years of age. It is recommended for infants beginning at birth in the hospital. All older children who did not get all the recommended doses of hepatitis B vaccine as an infant should complete their vaccine series as soon as possible. Adolescents who are just starting their series will need two or three doses, depending on their age and the brand of vaccine used.

Adults at increased risk of acquiring HBV infection should also be vaccinated. In addition, the vaccine can be given to any person who desires protection from hepatitis B.

After three properly administered doses of vaccine, at least 9 out of 10 healthy young adults and more than 9 out of 10 infants, children, and adolescents develop protective antibodies and subsequent immunity to HBV infection.

Normally a person will not become positive to Hbs Ag if he had taken the vaccination properly. However if a person was positive before the vaccination then he will not become negative after the vaccination. A positive person need not take the vaccine.

At the present time, booster doses are not recommended routinely for people with normal immune systems. As you have already taken the required doses repeat doses may not be needed. Although the level of protective antibodies in the blood of a vaccinated person seems to decline with time, the immune system retains an immunization "memory" and if the person is exposed to HBV, the system "kicks in" and provides the needed protection

15. J.D. Goa

*I am 40 years and have married in 2010 and I have one son. It was caesarean delivery the doctor had advised my wife not to conceive for three years. As I was working in abroad and every six months I get leave of 15 days, and for the last 18months I have tried but not succeed to get the second child. A month ago when I was in vacation I have noticed that I was having difficulty in erection, and also that my semen is very less and not so thick. Please suggest me to solve this problem.

** The anxiety of getting your wife pregnant may be real cause of erection difficulty in you. Other than this, at your age some of the men get diabetes mellitus which can affect erection. Get your blood sugar checked. If problem continues consult an urologist.
You may be aware that the healthy woman remains fertile for about 8 hours in a month and she might conceive only if there are healthy sperms in her genital tract at that time. There is every possibility that you might be missing the fertile period when you were with your wife once in 15 days in six months. There are several other factors that can affect the fertility. Let your wife also consult a gynaecologist to assess if there are any of these.

16. S.F. Kuwait

*Please suggest some medicine for vitiligo. I have consulted many doctors here as well as in India, but they couldn't treat me, they said I need not worry about it, because there was no itching or pain & they were not growing fast. About twenty years ago I found one, which was smaller than 1/2cm, which is now little bigger than 1/2cm. But now I am having 9-10 & very small patches. They are two types, one is plain white colour and the other has thick skin. Doctor had scraped the skin and tested, and said nothing to worry.

** Are you sure that the skin lesions you have are due to vitiligo? A small lesion which has not grown over the last twenty years may not create the problem now. As the doctors are sure that there was no benefit from advising medication, they must have suggested you not to go for treatment and not to worry. As more than one doctor are of the same opinion, it may be better if you stop worrying over the problem.

17. I.P., Mangalore

* My daughter is 14 years. She is clever, smart, good looking, active a dancer. But she stammers; certain days the stammering is too much and she gets upsets, though I encourage her to speak and advised her not to get upset. Advised her to read loudly, her teachers are also very helpful. What should we do to stop this stammering?

** Stammering problem can be reduced or overcome by speech therapy. Speech is one of our body's strongest habits and stammered speech is also a habit. Stammering is not a disease and therefore, it cannot be treated through medicines. The stammering child or adult has to be helped to develop a new, more fluent manner of speech through an intensive re-orientation program which focuses on modifying his physical manner of talking as well as changing his mental attitude towards the problem. Speech therapy is available in several centers in major cities in India and abroad. Other than speech therapy, yoga and meditation might really hold the key to solving the problem of stammering.

18. V.V. Mangalore

*We have been taking IVF treatment in well equipped hospital out of Mangalore. Two attempts have failed. Can we take embryoes to Mangalore and continue treatment in Mangalore?

** I presume you were adequately informed about the IVF programme. Couples considering IVF have to have full information about in vitro fertilization and about the outcome results of the program. Some IVF centres have very low pregnancy success rates. Other centres may have high success rates, but also a very high rate of triplet or higher multiple births. For these reasons, all couples considering IVF treatment should get a written statement of their clinic's recent successes rates and evaluate them in relation to other clinics. There are many factors that have an influence on IVF success, important of them are:

• The quality of the laboratory environment and the skill and experience of the embryology staff

• The skill and experience of the reproductive endocrinologist doctor (fertility specialist)

• The average number of embryos transferred per procedure

• The cases taken on by the program for IVF treatment. There are "good" patients and "bad" patients in the sense that some couples are more
likely than others to have success from IVF because of egg quantity and quality, age of the mother or other issues.

Some programs are very aggressive and push their in vitro fertilization success rates up by transferring high numbers of embryos. A program that transfers high numbers of embryos may have a high overall success rate, but too many of these will be triplets or quadruplets.

Triplet pregnancies are very high risk and need to be prevented as much as possible.

As on now there are no established IVF centres in Mangalore city but there are fertility clinics and you may approach them for guidance.

19. R.R., Mangalore

*I am 27 years of age. I had sex with my girl friend about two years ago, who left me and after coming to gulf I had relationship with sex workers about four times. I had used condom some times but not each time. Now I am scared that I might be infected with AIDS? I repent for all my past doings.

**Instead of worrying over the problem, it may be worth to get your blood checked for HIV. If it is negative, thank God and be careful. If it is positive, consult the hospitals where anti-retroviral medicines are given. These centres distribute the medicines free of cost after confirming the infection. These medicines help to reduce the effects of the disease on the body but can not cure the problem.

20. J.M.m Mangalore

* I am 46. Recently I noticed that lymph node below my left ear had enlarged and was paining. After the ultra sound and FNAC test it was diagnosed as tuberculosis infection. I have not started the medication and would do it in India. Do I have to do the test immediately? What are the preventive medications till I do the test?

**If FNAC (Fine Needle Aspiration Cytology) test has revealed tubercular infection, then it is almost definite that you have tuberculosis. Tubercular infection of the lymph nodes can be primary lesion or it may be secondary to the problem in some other organ. To avoid the disease spreading to other organs and to avoid the complications it is better to start the anti-tubercular medication at the earliest. There are effective and safe drugs against tuberculosis which can cure the disease completely. There are no other preventive steps other than taking anti-tubercular medication.