Category: Health / Kesihatan


Tidur mencukupi mengurangkan risiko menambahkan berat badan dan menyebabkan penyakit kencing manis

Lebih pendek masa tidur seseorang rasa lapar bertambah

Washington:   Tabiat tidur seseorang mampu menjejaskan kawalan berat badan dan kurang tidur dikaitkan dengan memberi kesan bukan hanya berapa banyak kalori yang kita ambil tetapi juga berapa banyak tenaga yang dibakar, kata satu kajian terbaru. Sejak beberapa tahun lalu, beberapa kajian epidemiologikal mendapati ada kaitan antara berapa lama tidur seseorang dan obesiti selain diabetes jenis kedua, yang merumuskan bahawa kurang tidur menambahkan risiko untuk menambahkan berat badan dan menyebabkan penyakit kencing manis.

Kesan tidur yang singkat boleh meningkatkan rasa lapar selain penggunaan tenaga serta aktiviti fizikal tubuh seseorang” – Kajian

Kajian oleh penyelidik Universiti Tubingen and Lubeck di Jerman dan Universiti Uppsala di Sweden menunjukkan kesan tidur yang singkat boleh meningkatkan rasa lapar selain penggunaan tenaga serta aktiviti fizikal tubuh seseorang.

Aktiviti fizikal diukur dengan alat khas yang dipakai pada pinggang untuk mengesan pecutan. Tenaga digunakan badan dinilai secara tidak langsung oleh kalorimetri, satu alat yang menganggarkan jumlah kepanasan dikeluarkan oleh seseorang ketika mereka menggunakan oksigen.

Kurang tidur akan meningkatkan rasa lapar selain turut menambahkan jumlah ‘hormon lapar’ ghrelin yang dikesan dalam darah seseorang.

Lebih pendek masa tidur seseorang, mereka akan mengalami lebih rasa lapar.
Berjaga selama satu malam juga akan mengurangkan jumlah tenaga digunakan oleh badan apabila berehat.

Kajian ini memaklumkan apabila kita kurang tidur, kita akan makan lebih banyak disebabkan rasa lapar. Ini boleh menyebabkan kita bertambah berat badan.
Bagaimanapun kurang tidur juga menyebabkan kita kurang membakar kalori yang menjadi tambahan kepada penambahan berat badan.

Kajian berterusan bertujuan untuk mengetahui jika menambahkan waktu tidur boleh membantu usaha mengawal berat badan.

Walaupun masih ada cara untuk menambahkan waktu tidur bagi merawat obesiti dan diabetes, keputusan penyelidikan sedia ada jelas menyokong tanggapan bahawa tidur membabitkan keseimbangan antara jumlah kalori yang kita ambil setiap hari dan jumlah yang digunakan melalui aktiviti dan metabolisme.

Source: Agensi

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Garis Panduan

 – Guidelines On Prevention And Management Of Tuberculosis For Health Care Workers In Ministry Of Health, Malaysia 
 – Standard Dan Borang Pemeriksaan Perubatan Bagi Permohonan Lesen Memandu Untuk Orang Kurang Upaya (Medical Examination Standards For Disabled Driver’s Licensing )
*Borang Pemeriksaan Perubatan Bagi Permohonan Lesen Memandu Untuk Orang Kurang Upaya
 – Guidelines For the Diagnosis, Management, Prevention and Control of Leptospirosis in Malaysia
Garis Panduan Kesihatan Antarabangsa
Garis Panduan Pengimportan Atau Pengeksportan Mayat Atau Mana-Mana Bahagiannya
Garis Panduan Pengimportan Atau Pengeksportan Organisma Atau Mana-Mana Bahagiannya
Garis Panduan Pengimportan Dan Pengeksportan Tisu Manusia Atau Mana-Mana Bahagiannya
Garis Panduan Pemeriksaan Kesihatan Kapal Di Pelabuhan
Garis Panduan Pemeriksaan Kesihatan Jemaah Haji
Guide to Ship Sanitation
Guide to Hygiene and Sanitation in Aviation
Garis Panduan Pengendalian Kanak-Kanak Di Taska dan Prasekolah
Guidelines For Clinical And Public Health Management Of Melioidosis In Pahang
Hand Foot And Mouth Disease (HFMD) Guidelines
Terma Rujukan Jawatankuasa Keselamatan dan Kesihatan Di Hospital-Hospital Kementerian Kesihatan Malaysia
Guidelines on Chemical Management in Health Care Facilities Ministry of Health
Standards and Guidelines for Medical Assistant Education Programme
Garis Panduan Program Kesihatan Pekerjaan
Guidelines on Approval and Accreditation of Optometry & Opticianry Programmes in Higher Education Institutions
Garis Panduan Penubuhan Lembaga Perubatan di Jabatan Kesihatan Negeri, Institusi Perubatan dan Hospital-Hospital Kementerian Kesihatan Malaysia
Garis Panduan Penyediaan Laporan Perubatan Di Hospital-Hospital dan Institusi Perubatan Kementerian Kesihatan Malaysia
Guidelines on Standards & Criteria for Approval/Accreditation of Nursing Programmes
Panduan Penggunaan Kemudahan  Fasiliti Program Kesihatan Awam untuk tujuan latihan lapangan pelajar IPTA/IPTS
Garis Panduan Pengurusan Kesinambungan Perkhidmatan – Perkhidmatan Agensi Sektor Awam
Guideline on Medication Error Reporting
Garis Panduan Farmakovigilans Keselamatan Vaksin di Malaysia
Safe Surgery Save Lives – Implementation Guidelines
Garis Panduan Pengendalian Influenza A (H1N1) di Klinik Kesihatan
Buku Panduan Penggunaan Khidmat Doktor Swasta Untuk Perkhidmatan Kesihatan Di Klinik Kesihatan
-. National Antibiotic Guideline 2008
Standard Operating Procedure (SOP) For Hearing Aid Prescription And Fitting
Garis Panduan Berkaitan Perkhidmatan Stem Cell
Garis Panduan Pendaftaran Orang Kurang Upaya
Garis Panduan Penggunaan Fasiliti Kementerian Kesihatan Malaysia (KKM) Untuk Latihan Amali oleh Institut Pengajian Tinggi Awam (IPTA) Dan Institut Pengajian Tinggi Swasta (IPTS) Bagi Program Pengajian Kejururawatan
Guidelines for High Risk Neonatal Hearing Screening
Malaysian Guidelines in the Treatment of Sexuality Transmitted Infection – Third Edition

Here are tips to guide you to quit smoking:

  • Chew on gum or fruits but avoid anything sweet.
  • Wash your hands. Wet hands will deter you from picking up a cigarette.
  • Shower more frequently.
  • Pray for God to strengthen your determination and effort.
  • Turn your attention to exercise.
  • Get support from your family and friends.

Here are more tips to guide you to quit smoking:

  • Delay lighting up for five (5) minutes or longer.
  • Drink lots of water. Avoid coffee and tea.
  • Keep busy to distract yourself from smoking.
  • Avoid situations or areas that smokers frequent.
  • Pick a quit day and work towards it.
  • Get help at your nearest Perkhidmatan Berhenti Merokok [1].

80% of neck cancer victims are smokers. 90% of lung cancer victims are smokers.

Quit now! Smoking doesn’t pay.

References

  1. Ministry of Health Malaysia, Health Education Division, Siri Tak Nak Merokok Health Campaign Brochure
  2. ^ Since January 2007, the Ministry of Health Malaysia has provided a hotline service to aid smokers in giving up their habit. This hotline is known as Infoline Berhenti Merokok at 03-88834400. It operates daily during working hours. Infoline Berhenti Merokok is hosted by the Health Education Division of the Ministry of Health Malaysia. Services provided: Advice on quit smoking; Tips to quit smoking; and Quit Smoking Clinic. Operating Hours: 8.00 a.m. – 5.00 p.m. Mondays to Fridays (working days only).

The increasing incidence of tuberculosis (TB) among healthcare workers has prompted the Health Ministry to issue a set of guidelines to prevent the spread of the disease in local healthcare facilities.

According to the guidelines, the number of healthcare workers (nurses, medical attendants and doctors) that are diagnosed with TB has increased from 106 in 2007 to 220 in 2010.

“The problem is that healthcare workers often do not think of TB, and they do not take precautions,” said Institute of Respiratory Medicine director Datuk Dr Abdul Razak Muttalif.

Healthcare workers face a higher risk of getting infected compared to the general population as they come into contact with patients with TB more often and for a longer duration.

However, as the most common symptom of TB cough is also common in many other diseases, many healthcare workers do not think of TB when they are treating patients with cough.

“The TB guidelines we have tells us that if a person coughs for more than two weeks, we should suspect TB. However, not many people are practicing it, ” Dr Abdul Razak said.

TB transmission can be easily prevented by asking patients who are coughing to wear a mask and avoid spitting in public places.

The disease is also curable if patients take a combination of at least three or four antibiotics for about six months.

“Unfortunately, many people still die from the disease because they come late,” Dr Abdul Razak said, adding that less than 15% of patients cough out phlegm with blood.

The new guidelines issued by the ministry involve advice on environmental controls, administrative controls (managerial) and the use of personal protective equipment like face masks to prevent the spread of TB.

Dr Abdul Razak said that hospital staff who are diagnosed with TB will be given a long medical leave until their sputum test (a lab test for TB) comes back negative.

“TB is curable, so there is no reason why anyone should be sacked from their jobs,” Dr Abdul Razak said.

“The idea is to catch them early, treat them effectively, and make sure that they do not spread the disease to other people,” he added.

Primary prevention to reduce the incidence of stroke should be targeted at the whole population and groups that are at increased risk by increasing awareness and promoting healthy lifestyles that reduce the risk factors for stroke.

THE brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage, and possibly death of the brain cells.

A stroke, which is also called a cerebrovascular accident (CVA), is a condition in which the blood supply to a part of the brain is cut off. It is a medical emergency and the earlier treatment is provided, the less likely will be the damage.

Strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum (i.e. every hour, six people experience a stroke).

The risk for recurrent vascular events after a stroke or transient ischaemic attack (TIA) is about 5% per year for stroke, 3% per year for heart attack, and 7% per year for any one of stroke, heart attack or vascular death. The risks are higher in patients who are at an increased risk of CVA or who have carotid stenosis.

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA.

As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes.

Risk factors

A risk factor increases the chances of getting or having a certain health condition. Some risk factors for stroke cannot be changed, but others can be prevented. Changing risk factors over which a person has control will assist in achieving a longer and healthier life.

Strokes are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

·Age – The risks are increased in the older person, although about a quarter of strokes occur in the young. The risk doubles in each successive decade after 55 years of age.

·Gender – The risks are increased in males (except in older adults, when it evens out).

·Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.

·Medical history – The risks are increased if one has had a heart attack, stroke or TIA. The risks are also increased in pregnancy, abnormal heart beats, chronic renal disease, cancer, some types of arthritis, and in those with abnormal blood vessels or weakness in the wall of an artery.

·Family history – The risks are increased if a close relative has had a stroke.

Primary prevention is vital in any programme to reduce the incidence of stroke. This should be targeted at the whole population and groups that are at increased risk by increasing awareness and promoting healthy lifestyles that reduce the risk factors for stroke.

Secondary prevention are measures used to prevent recurrence of a stroke. They are individualised depending on the person’s pathogenesis based on neuroimaging and other investigations.

The prevention of stroke is similar to the prevention of coronary heart disease.

High blood pressure

High blood pressure (hypertension) is a major risk factor for stroke. The incidence increases in proportion to both the systolic and diastolic blood pressures. Isolated systolic hypertension (systolic blood pressure of more than 160mm Hg and diastolic blood pressure of less than 90mm Hg) is an important risk factor for senior citizens.

A reduction in blood pressure reduces the incidence of stroke. A reduction of the systolic blood pressure by 10mm Hg is associated with a reduction in risk of stroke by about a third, regardless of the baseline blood pressure levels.

Hypertension is controlled by diet, exercise and medicines.

Hyperlipidaemia

There is an association between raised blood lipids and risk of ischaemic stroke. Hyperlipidaemia is controlled by diet, exercise and medicines.

The use of statins in those at increased risk, e.g. those with cardiovascular disease, diabetes, reduces the incidence of coronary events and ischaemic strokes even in individuals whose blood cholesterol levels are normal (less than 5.0mmol/L).

Diabetes

Diabetes increases the risk of ischaemic stroke by 1.8 to 6 times. The incidence of stroke is significantly reduced by stringent control of hypertension in diabetics.

Scientific studies have indicated that strict control of the blood glucose (Hb A1c less than 6%) is critical.

Diabetes is controlled by diet, exercise and medicines.

Diet

Foods rich in fat lead to fatty deposits in the artery walls. The overweight are at risk of hypertension. A low-fat, high-fibre diet, which includes abundant fruits and vegetables (at least five servings daily), is recommended.

Unsaturated fats which increase the blood cholesterol, e.g. meat, ghee, lard, should be avoided. However, a balanced diet has to include some unsaturated fat like fish, olive and vegetable oils.

The daily intake of salt should not be more than 6gm (0.2 oz), which is about one teaspoonful.

Exercise

A combination of a healthy diet with regular exercise is the best method to maintain a healthy weight, which reduces the risk of developing hypertension.

Regular exercise ensures that the heart and circulation are efficient, keeps the blood pressure normal, and lowers the blood cholesterol.

The recommendation is that there be at least 150 minutes of exercise of moderate intensity, e.g. fast walking, per week (about 30 minutes daily).

A person who has had a stroke should discuss with his healthcare provider about possible exercise plans. It may not be possible to have regular exercise immediately after a stroke, but exercise should begin when there has been progress with stroke rehabilitation.

It is essential that weight be maintained at healthy levels. Many people go on weight reduction programmes only to find that they gain back the kilogrammes they lost. It would be better to accept a steady rate of weight loss instead of overnight success.

Programmes that promise an ideal weight within a short period of time do not usually work out in the long term. The key to keeping the weight loss is to make changes to diet and lifestyle that one can live with. One has to adhere to these changes for life; they have to be part and parcel of everyday life.

Smoking

Both active and passive smoking increase the risk of stroke. Smoking doubles the risk as it leads to narrowing of the arteries and increases the likelihood of the blood clotting.

Smoking cessation can reduce the risk of a stroke by up to half. In addition, it will also improve general health and reduce the risk of developing other serious conditions like heart disease and lung cancer.

Smokers who have stopped for more than five years have the same risk of stroke as non-smokers.

Alcohol consumption

Heavy alcohol consumption increases the risk of stroke by three times as it can lead to high blood pressure and irregular heart beats, which are both major risk factors for stroke. In addition, alcohol causes weight gain because they are high-calorie compounds.

Consumption of more than three units a day (one unit = one glass of wine = a peg of hard liquor) increases the risk while light or moderate alcohol intake protects against all strokes.

Aspirin

Aspirin has been reported to be of benefit to women aged 65 years or more in the primary prevention of stroke due to its blood thinning effects.

There is substantial evidence of the benefits of aspirin in secondary prevention of recurrent strokes, with a 25% reduction in risk in all patients with strokes who have received aspirin.

When given within 48 hours of a stroke, it has also been beneficial in reducing recurrent strokes and death.

Other anti-platelet medicines

Alternative antiplatelet medicines are prescribed in patients intolerant or allergic to aspirin, have contraindications to aspirin, or when aspirin has failed. The medicines include ticlopidine and clopidogrel.

It is essential to take aspirin or other anti-platelet medicines under the supervision of a doctor. In addition, one should take measures to avoid falls or tripping when taking these blood-thinning medicines.

In a nutshell

There are several measures that can be taken to prevent a stroke or a recurrent stroke, if one has had a stroke. The following will reduce the likelihood of a stroke or recurrent stroke:

  • Control high blood pressure through diet, exercise, and medicines, when necessary.
  • Control diabetes through diet, exercise, and medicines, when necessary.
  • Control raised cholesterol through diet, exercise, and medicines, when necessary.
  • Exercise at least 30 minutes a day.
  • Maintain a healthy weight by eating healthy foods, eating less, and joining a weight reduction programme, if necessary.
  • Do not smoke, or stop smoking.
  • Limit alcohol consumption to one drink a day for women and two a day for men.
  • Avoid illicit drugs.
  • Have regular medical checks and consultations with the family doctor or physician.

Source: Dr Milton Lum

The harder you work during rehabilitation, the better your chances of significant recovery after a stroke.

THERE are many questions that come to the minds of stroke victims and their caregivers. Some people view a stroke negatively, whilst others take up the challenge of recovery and restoration of function as much as is possible.

Importantly, the stroke victim’s attitude has a substantial influence on recovery.

The care of stroke patients requires a multidisciplinary approach. The ideal is for all stroke patients to be managed in a stroke unit, which is a dedicated unit in the hospital that only manages strokes. Such a unit would be staffed by neurologists, geriatricians, general physicians with an interest in stroke, trained nurses, physiotherapists, occupational therapists and speech therapists. It would also include neurosurgeons, social workers and dietitians.

The extent of recovery of motor functions is often influenced by the extent of compliance with the rehabilitation plan.

The specially trained staff of the unit provides co-coordinated multidisciplinary 24-hour care throughout the year. There is ample evidence that stroke patients managed in such units have significantly lower death, dependency and institutionalisation rates. In addition, their length of hospital stay is lower when compared to management in general medical wards.

The benefits of a stroke unit include early acute treatment, reduced infection rates, reduced systemic complications and effective rehabilitation. The benefits are independent of the patients’ age, gender, extent of the stroke and the presence of other medical conditions.

The functioning of a stroke unit is enhanced by an efficient referral and rehabilitation network that includes the family doctor.

Cognitive matters

Every human brain has processes and functions which it uses to process information from the environment. These cognitive functions include thinking, memory, concentration, communication skills, spatial awareness and praxis, which is the ability to carry out skilled physical activities.

After a diagnosis of stroke has been made, the doctor and other healthcare professionals will make an assessment of the patient’s cognitive functions, especially the degree to which it has been affected by the stroke.

The assessments, which may take a few days to be completed, enable the formulation of treatment and rehabilitation plans that are specific for the individual patient.

Most cognitive functions affected by the stroke will return with the passage of time, especially with compliance to the treatment and rehabilitation plans. However, full recovery may not occur in some patients.

Many stroke patients have problems with understanding, speech, reading and writing, a condition called aphasia. This results from damage to the part of the brain that controls language, or the muscles involved in speech may be affected.

In such situations, the patient’s recovery of cognitive functions will require interactions with other healthcare professionals, e.g. a speech therapist to assist in the recovery of communication skills.

Various other methodologies are used to assist the patient who has lost some particular cognitive function, e.g. memory aids or diaries for daily tasks.

Recovering physical functioning

Many stroke patients have weakness or paralysis of one side of the body. Many also have difficulties with balance and co-ordination of the body’s movements.

There is often marked tiredness in the initial weeks after the stroke. There may also be problems getting to sleep, thereby aggravating the tiredness.

As soon as a patient’s medical condition permits, he or she should be attended to by a physiotherapist who will formulate a treatment and rehabilitation plan after making an assessment of the degree of physical disability. The primary goal of rehabilitation is to achieve an improvement in the patient’s functional status.

There are various phases in a rehabilitation plan. It starts with evaluation, which is followed by setting of objectives, delivery of management, task reacquisition and environmental modification.

The initial objectives are to improve balance and then to regain muscle strength and control. The exercises are of a short duration initially, which then increases with the recovery of motor function, e.g. the patient may have to pick up an object initially, and later, stand up and walk.

It is vital to follow the instructions and advice of the physiotherapist, although progress may be perceived as difficult and slow initially. The extent of recovery of motor functions is often influenced by the extent of compliance with the rehabilitation plan.

The involvement of a family member or caregiver is always encouraged because the physiotherapist can teach the patient and the caregiver the exercises that can be carried out at home.

The duration of physiotherapy varies and can last for months, or sometimes, years. The decision as to when to stop physiotherapy should only be made after a full discussion with the doctor and physiotherapist.

Bladder and bowel function may be affected if the part of the brain which controls these functions is damaged by the stroke. This can lead to urinary and/or bowel incontinence.

Most patients recover these functions within a fortnight or so. If the problem persists, help could be sought from nurses, and supplemented by aids like incontinence pads.

There are occasions when a stroke leads in damage to the parts of the brain that receive, process and interpret information from the eye(s). This results in various visual problems like double vision, and partial or total blindness in one eye. The management of these problems would require the expertise of an eye specialist (ophthalmologist).

Some patients give up on sex after a stroke. It is important to know that sex does not increase the risk of another stroke. Although there is no guarantee that another stroke will not recur, there is no reason why it should occur while having sex.

Other ways of having sex can be found even if there is severe disability. If there are any problems, a discussion with the doctor will be helpful. This is especially so as sex drive (libido) is reduced by certain medicines.

Some stroke patients enquire about driving. This depends on residual disabilities and the type of vehicle in question. An assessment by a specialist or family doctor will be helpful. The patient’s medical status and the safety of other road users will have to be taken into consideration.

Psychologically speaking

The majority of psychological disorders after a stroke are depression, in which there are feelings of hopelessness and withdrawal from social life, and anxiety disorder, in which there is intense and often uncontrollable fear and anxiety.

These psychological disorders impact upon family and sexual relationships. They are common but will usually disappear with the passage of time. Doctors and other healthcare professionals will provide advice and assistance in addressing the psychological aspects of stroke. They will usually carry out regular reviews of the patient’s psychological functioning.

If the psychological disorders are severe or persistent for a long period of time, a referral will be made to a psychiatrist, who will use various modalities to manage the patient. This includes medicines, counselling and cognitive behavioural therapy.

Looking towards the future

After a stroke, many patients and their caregivers are interested in what the future holds (prognosis) .

The prognosis of stroke depends on the type, size and location of the pathology. A Malaysian study in 2003 reported that mortality is higher in haemorrhagic stroke (27.3%) compared to ischaemic stroke (11%). However, there is better neurological and functional recovery in haemorrhagic stroke.

Strokes that involve the brainstem or are large have a poorer prognosis. The lowest mortality rates are in small focal strokes.

Deaths in the initial month after a stroke are often due to direct effects of the brain damage. Subsequent mortality is usually due to the complications of immobilisation, i.e. bronchopneumonia, deep vein thrombosis, recurrent stroke and coronary heart disease.

In general, a third will recover almost completely and should be able to lead a normal life. Another third will have substantial disability which is variable, eg requiring assistance with bathing (which is mild) and assistance with getting in and out of bed (which is severe). Another third will be severely affected and will die within a year, with the majority of deaths occurring in the initial weeks after the stroke.

Recent studies have reported that mortality rates after a first-ever stroke (all types) were 10% at one week, 20% at one month, 30% at one year, 60% at five years and 76% at 10 years.

The risks of recurrent stroke are 4% in the first month and 12% in the first year. The risks decrease subsequently to about 4-5% per year so that 30% will have suffered a recurrent stroke five years after the first stroke.

The incidence of deaths following a stroke has decreased in the past few decades in both sexes. This has been due to the introduction of stroke units and better prevention in those with risk factors.

Source: Dr Milton Lum

The management of stroke and ‘mini-strokes’. THE brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage and possibly death of the brain cells.

A stroke, which is also called a cerebrovascular accident (CVA), is a condition in which the blood supply to a part of the brain is cut off.

A transient ischaemic attack (TIA) is due to a temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. Its features are similar to that of a stroke, but the duration is about a few minutes. The TIA usually resolves within 24 hours.

TIAs provide a warning that further TIAs or a stroke is on the way.

The incidence of TIA is not well known as many people who have TIA do not seek medical attention.

Imaging tests like computerised tomography (CT) scan and magnetic resonance identify the type of stroke and TIA, its location in the brain and the extent to which the brain is affected. – Courtesy of HSC Medical Centre

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA. As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes.

Strokes and TIAs are medical emergencies, and the earlier management is instituted, the less likely will be the damage to the brain, and consequently, the affected part of the body.

Making a diagnosis

There are two main types of strokes.

Ischaemic strokes, which comprise the majority of stroke cases, occur when the blood supply to the brain stops because the vessel is blocked by a blood clot. This may be due to thrombosis, in which a blood clot forms in one of the brain’s arteries, or to an embolism, in which a blood clot formed elsewhere in the body gets into the brain’s arteries to reach a blood vessel small enough to block its passage.

Haemorrhagic strokes occur when bleeding results from the bursting of a blood vessel supplying the brain because of weakness in its wall. The blood collection compresses the brain, causing damage and loss of function.

The diagnosis of stroke and TIA is made from a detailed history-taking, physical examination and selected diagnostic tests. The history provides vital information, and every effort should be made to obtain information from the patient, family members, friends, or witnesses.

The diagnosis provides answers to questions about the type of stroke, its site in the brain, the extent to which the brain is affected, why it occurred, as well as the potential complications and prognosis.

The investigations for stroke and TIA have been discussed in previous articles. Imaging tests like computerised tomography (CT) scan and magnetic resonance identify the type of stroke and TIA, its location in the brain and the extent to which the brain is affected.

Ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan) help to identify causes of stroke and TIA. Dye may be injected into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

Other tests include blood tests like clotting factors, glucose and cholesterol, electrocardiogram to detect any abnormal heart rhythms, and chest and other x-rays to exclude other medical conditions.

Managing ischaemic strokes

The restoration of perfusion to the ischaemic brain is a vital therapeutic strategy. Although a core of brain tissue might not be salvageable in a stroke, the adjacent dysfunctional tissue may be saved if its circulation is restored and metabolism is normalised.

Ischaemic strokes are treated with medicines that dissolve blood clots (thrombolysis). These medicines are effective if given intravenously within about three to four hours after the onset of the stroke. After that, the medicine has not been shown to have beneficial effects. The earlier thrombolysis is instituted, the better the likelihood of recovery. However, thrombolysis cannot be prescribed for all patients.

Patients will also be prescribed aspirin, which reduces the stickiness in platelets, thereby reducing further blood clot formation. Other medicines will be prescribed if there is allergy to aspirin.

Some patients may be prescribed blood thinning (anti-coagulant) medicines, i.e. heparin or warfarin, that alter blood composition to prevent blood clot formation. However, the use of heparins is not routinely recommended as it does not reduce the mortality in patients with ischaemic stroke.

Anticoagulants are often prescribed in those with an irregular heartbeat.

Ischaemic strokes that are due to narrowing (stenosis) of the carotid artery in the neck are treated surgically, especially if the stenosis is severe. A surgical incision is made in the neck and the fatty deposits in the carotid artery removed.

Management of haemorrhagic strokes

Haemorrhagic strokes are managed by emergency surgery to remove blood from the brain and to ligate any burst blood vessels. The procedure, called a craniotomy, involves a surgical incision of the skull to allow access to the bleeding site(s). After the blood collection has been removed and any bleeding stopped, the bone removed from the skull will be replaced.

The patient may need to be put on a ventilator in the intensive care unit to assist his or her breathing. Medicines will also be prescribed to reduce the likelihood of further strokes, e.g. medicines to lower blood pressure and reduce swelling of the brain (cerebral oedema).

General management of strokes

The objectives are to provide supportive care and treatment of acute complication(s) in order to avoid mortality and functional disability.

Oxygen and airway support are necessary to ensure adequate tissue oxygenation and potential worsening of brain injury.

Regular monitoring and observations are necessary for detection of impaired lung and circulatory function. As high blood pressure is common following a stroke, it is gradually reduced with various medicines.

As there is an association between raised blood sugar following an acute stroke and subsequent mortality and impaired recovery, whether in diabetics or non-diabetics, it is vital that the blood sugar be well controlled.

Strokes may lead to impaired swallowing and consequent aspiration, which increases mortality. As such, a water-swallowing test is performed in all stroke patients before they are allowed to drink or eat. Incomplete oral-labial closure or a coughing reflex is indicative of an increased risk of swallowing. If the patient fails the swallowing test, a nasogastric tube is inserted for feeding.

When a fever occurs, doctors will localise the infection. Antibiotics are prescribed for infections, especially of the lungs and urinary tract, which are the commonest complications after a stroke.

Urinary catheters are avoided, if possible. Anti-pyretics are prescribed for fever, which is also associated with an increased risk of mortality and morbidity.

The majority of stroke patients are prescribed bed rest initially. Mobilisation is initiated as soon as the patient’s condition is stabilised (to prevent complications). Frequent turning, alternating pressure (ripple) mattresses and passive and full-range-of-motion exercises are beneficial.

There has to be close skin monitoring for early detection of bed sores and measures have to be taken to avoid falls.

Management of TIA

The objective is to address the risk factors that led to TIAs in order to prevent a stroke from occurring.

The treatment prescribed depends on the cause(s) of the TIA. High blood pressure, which is the single most important risk factor, is treated with hypotensive medicines.

High blood cholesterol levels are treated with diet, exercise and statins.

Diabetes is treated with diet, exercise, oral hypoglycaemic agents or insulin.

Smoking cessation is vital as smoking doubles the likelihood of TIA or stroke because of the chemicals in the cigarette.

Carotid artery stenosis may require surgery (endarterectomy) to remove the fatty plaques.

Time is of the essence

The effective treatment of stroke and TIA saves lives and prevents long-term disability. The window of opportunity is no more than three to four hours in the case of stroke. Therefore, it behoves everyone with risk factors of stroke and TIA and their caregivers to remember that time is of the essence. In short, TIME = BRAIN.

Source: Dr Milton Lum

Transient ischaemic attack is a warning sign that a stroke may just be around the corner.

A TRANSIENT ischaemic attack (TIA) is due to a temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. Its features are similar to that of a stroke, but the duration is about a few minutes. The TIA is usually resolved within 24 hours.

TIAs provide a warning that further TIAs or a stroke is on the way. Its incidence is not well known as many people who have TIA do not seek medical attention. However, strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum, i.e. strokes occur in six persons every hour.

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA. As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes. Its early investigation and treatment will markedly reduce the risk of another TIA or stroke.

High blood pressure (hypertension) is the single most important risk factor for stroke.

Anatomy of a TIA

The brain receives its blood supply primarily from the carotid arteries in the front of the neck and secondarily from the vertebral arteries in front of the backbone. These arteries branch into smaller vessels that supply blood to all parts of the brain.

One of these smaller blood vessels gets blocked off during a TIA. This blockage is temporary, lasting a few minutes, and the blood supply is restored soon after, unlike a stroke, in which the blockage lasts a longer period of time. The lack of a constant supply of oxygen-rich blood leads to damage, and later, death of the brain cells.

The blockage is due either to a narrowing of the arteries or as a result of a blood clot formed elsewhere in the body getting into the brain’s arteries to reach a blood vessel small enough to block its passage.

The brain’s arteries are narrowed or blocked by cholesterol deposits (plaques) on its inner lining due to atherosclerosis. Everyone’s arteries get narrower with age, but the process is hastened by factors like high blood pressure, poorly controlled diabetes, raised blood cholesterol, obesity, smoking, excessive alcohol intake, obesity, and a family history of diabetes or heart disease.

TIAs can also result from blood conditions like leukaemia, abnormally thickened blood (polycythaemia), or overproduction of platelets (thrombocythemia).

A TIA can result from blood clots formed in an artery (from elsewhere in the body), which gets “thrown” off (emboli) and eventually blocks the brain’s blood supply. This may be due to irregular heartbeats, the causes of which include high blood pressure, coronary artery disease, disease of the heart’s mitral valve, overactive thyroid gland and excessive alcohol intake.

It is rare that a brain haemorrhage causes a TIA.

TIAs, like strokes, are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

·Age – The risks are increased in the older person, although TIAs can occur at any age, including the young.

·Gender – Men are more likely to have TIAs than pre-menopausal women. However, the likelihood of TIA and stroke increases in postmenopausal women. Although the reason for this is not well elucidated, it is believed that the female hormones, oestrogen and progesterone, affect the elasticity of the body’s ateries.

·Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.

·Medical history – The risks are increased if one has had a heart attack, stroke or TIA.

·Family history – The risks are increased if a close relative has had a TIA or stroke.

There are several other factors (preventable) that increase the risks of TIAs and strokes. They include:

·High blood pressure (hypertension) is the single most important risk factor. The hypertension leads to extra strain on the arteries, causing them to narrow or be easily blocked.

·Diet – Atherosclerosis is more likely to develop with a diet high in saturated fats and excessive salt intake.

·Diabetes increases the likelihood of TIA because of the increased risk of atherosclerosis.

·Smoking doubles the likelihood of TIA or stroke because the chemicals in the cigarette smoke cause thickening of the arteries, thereby increasing the likelihood of clotting.

Features of TIA

The features vary depending on the part of the brain that is affected and the extent to which it is affected.

The common features of TIAs and strokes are:

·Face – There may be an inability to smile, open the mouth or the face or eye may hang downwards.

·Arms – There may be an inability to lift one or both arms due to numbness or weakness.

·Legs – There may be an inability to move one or both legs due to numbness or weakness.

·Speech – There may be slurring of speech or an inability to talk at all although awake.

Other features may include sudden vision loss, dizziness, difficulty talking and understanding what others say, difficulty swallowing, balancing problems, sudden headache, and blacking out.

Diagnosis

Immediate medical attention should be sought if one has or knows another person who has features of a TIA. This will reduce the likelihood of another TIA or stroke.

The diagnosis of a TIA is made by history taking and physical examination even if one thinks that the symptoms have gone. The objective is to check the patient’s neurological status and to rule out other conditions which may have caused the symptoms.

If a TIA is suspected, a referral will be made to a physician, geriatrician or neurologist for further evaluation. This should be done within a week of the occurrence of a TIA and immediately if there is more than one TIA in a period of seven days.

There are several investigations that are carried out after a TIA to check for the underlying conditions that may have caused it. They include:

·Blood tests like clotting factors, glucose, cholesterol

·Electrocardiogram to detect any abnormal heart rhythms

·Chest x-ray may be done to exclude other medical conditions

·Imaging

The common methods of brain imaging are computerised tomography (CT) scan and magnetic resonance imaging (MRI).

The CT scan involves multiple x-ray imaging to produce detailed three dimensional images of the brain and will provide information about factors that may have caused the TIA, e.g. haemorrhage or tumour. The MRI involves use of magnetic and radio waves to produce detailed images of the brain.

Both the CT scan and MRI are used to take images of the brain’s blood vessels as well the blood vessels in the neck that connect the heart and the brain’s blood vessels. This procedure, called a CT or MR angiogram, involves injecting a dye into a vein in the arm.

The brain imaging modality used depends on the availability of CT scan and/or MRI.

Other investigations of the cardiovascular system will be carried out to determine the cause of the TIA. It includes ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan). It can also include injecting dye into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

The management of TIA will be discussed in a subsequent article.

Source: Dr Milton Lum

When blood supply to the brain is compromised, it can lead to damage, and possibly death, of the brain cells, a condition called stroke.

THE human brain has been compared to a supercomputer. But the brain is much more complicated than that, a fact that is confirmed with each new discovery about its capabilities, which is still largely unknown.

This single organ controls all the body’s functions, which include heartbeat, breathing, sexual function, thinking, speech, memory, emotions, movement, and sleep. It influences the immune system’s response to ill health, and determines, to some extent, how a person responds to medical treatment.

In short, the brain makes us human and separates us from other living creatures on planet Earth.

The brain, which is encased in the bony skull, is divided into two sides (hemispheres), each controlling the opposite side of the body.

Different parts of the brain have different functions. The frontal lobe is responsible for the highest intellectual functions like thinking and problem-solving. The parietal lobe is responsible for sensory and motor function. The hippocampus is involved in memory. The thalamus is the relay station for almost all of the information coming into the brain, and the hypothalamus, the relay stations for the systems regulating the body’s functions.

The midbrain has cells that relay specific sensory information from the sense organs to the brain. The hindbrain comprises the pons and medulla oblongata, which control breathing and heart functions, and the cerebellum, which controls movement and cognitive processes that require precise timing.

The brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage, and possibly death, of the brain cells. This is called a stroke.

A stroke, also called a cerebrovascular accident (CVA), is a condition whereby the blood supply to a part of the brain is cut off. It is a medical emergency, and the earlier treatment is provided, the less severe it will be.

Strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum, i.e. strokes occur in six persons every hour.

Different types

There are two main types of strokes.

Ischaemic strokes, which comprise the majority of stroke cases, occur when the blood supply to the brain stops because the vessel is blocked by a blood clot. This may be due to thrombosis, in which a blood clot forms in one of the brain’s arteries, or to an embolism, in which a blood clot formed elsewhere in the body gets into the brain’s arteries to reach a blood vessel small enough to block its passage.

Haemorrhagic strokes occur when bleeding results from a burst blood vessel supplying the brain because of weakness in its wall. The blood collection compresses the brain, causing damage and loss of function.

A related condition is transient ischaemic attack (TIA) in which there is temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. As TIAs provide a warning that a stroke is on the way, they should be treated seriously.

Causes of stroke

Strokes are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

·Age – The risks are increased in the older person, although about a quarter of strokes occur in the young.

·Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.

·Medical history – The risks are increased if one has had a heart attack, stroke, or TIA.

·Family history – The risks are increased if a close relative has had a stroke.

Ischaemic strokes occur when the brain’s blood supply is blocked by clots formed where the arteries are narrowed or blocked by cholesterol deposits due to atherosclerosis.

Everyone’s arteries get narrower with age, but the process is hastened by factors like high blood pressure, poorly controlled diabetes, raised blood cholesterol, smoking, excessive alcohol intake, obesity and a family history of diabetes or heart disease.

An irregular heartbeat leads to blood clots being thrown off to block the brain’s blood supply. The causes of irregular heartbeats include high blood pressure, coronary artery disease, disease of the heart’s mitral valve, overactive thyroid gland and excessive alcohol intake.

Haemorrhagic strokes occur when a blood vessel of the brain bursts, resulting in bleeding into the brain itself (intracerebral haemorrhage). Sometimes, the bleeding is on the brain surface (subarachnoid haemorrhage).

The primary cause of haemorrhagic stroke is high blood pressure, the risk factors of which include smoking, overweight or obesity, lack of exercise, excessive alcohol intake and stress.

Blood-thinning medicines can also cause haemorrhagic strokes, which can also occur from blood vessel malformations in the brain or an aneurysm, which is a balloon-like swelling of a blood vessel.

Trauma can also cause bleeding in the brain. Although the cause is usually apparent, bleeding into the brain’s lining (subdural haematoma) may occur without signs of trauma.

A rare cause of stroke is blood clot formation in the brain’s veins, which is usually due to clotting abnormalities.

Signs and symptoms

The features vary depending on the part of the brain that is affected and the extent to which it is affected. Strokes usually occur suddenly.

The common features are:

·Face – There may be an inability to smile, open the mouth or the face or eye may hang downwards.

·Arms – There may be an inability to lift one or both arms due to numbness or weakness.

·Legs – There may be an inability to move one or both legs due to numbness or weakness.

·Speech – There may be slurring of speech or an inability to talk at all.

Other features may include sudden vision loss, dizziness, difficulty talking and understanding what others say, difficulty swallowing, balancing problems, sudden and severe headache, and blacking out.

Awareness of the above features is crucial, particularly for those at increased risk of a stroke, and their caregivers.

The complications of stroke include swallowing problems (dysphagia), which affect about a third of stroke patients. This leads to small food particles entering the respiratory tract causing lung infection (pneumonia).

Stroke can also lead to excess cerebrospinal fluid (CSF) in the brain’s ventricles (hydrocephalus) in about 10% of haemorrhagic strokes. CSF, which is produced by the brain, is continuously drained away and absorbed by the body. When its drainage is stopped following a haemorrhagic stroke, the excess CSF causes headaches, loss of balance, nausea and vomiting.

A small percentage of stroke victims who have lost some or all movement in their legs will have blood clot formation in their legs. The features of this deep vein thrombosis (DVT) include swelling, pain, tenderness, warmth and redness, especially in the calf. Urgent diagnosis and treatment is necessary to avoid the clot moving to the lungs, causing pulmonary embolism, which is potentially fatal.

Diagnosing stroke

The diagnosis of a stroke is made by history taking and physical examination. However, imaging of the brain is essential to determine if it is an ischaemic or haemorrhagic stroke, the part of the brain that is affected, and the severity of the stroke.

As the treatments of the different types of stroke vary, a speedy diagnosis will facilitate its management.

The common methods of brain imaging are computerised tomography (CT) scans and magnetic resonance imaging (MRI).

The CT scan involves multiple x-ray imaging to produce detailed three-dimensional images of the brain. MRI involves the use of magnetic and radio waves to produce detailed images of the brain.

Both the CT scan and MRI are used to take images of the brain’s blood vessels, as well as the blood vessels in the neck that connect the heart and the brain’s blood vessels. This procedure, called a CT or MR angiogram. involves injecting a dye into a vein in the arm.

The brain imaging modality used depends on the availability of a CT scan and/or MRI. A CT scan provides enough information if the suspected stroke is major. The MRI is useful if there are complex symptoms, the extent or location of the affected area is unknown, and in patients who have recovered from a TIA.

Brain imaging should be done early; in some patients, within an hour of admission.

A swallow test is usually done for all stroke patients because of the risk of aspiration pneumonia due to dysphagia. This involves giving a few teaspoons of water to the patient and if there is no choking or coughing, to be followed by half a glass of water.

Other investigations of the cardiovascular system will be carried out to determine the cause of the stroke.

It includes ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan). It can also include injecting dye into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

The management of stroke will be discussed in a subsequent article.

Source: Dr Milton Lum

The term autism encompasses a range of behaviours that adversely affect social interaction and communication.

AUTISM is a developmental disability that results in problems with social interaction and communication. Its features vary with individuals.

One person may have mild symptoms, whilst another may have serious ones. That is why healthcare providers consider autism a “spectrum” disorder, which includes an autistic disorder, Asperger syndrome, and pervasive developmental disorder (atypical autism).

Children who have an autistic disorder have major problems with language, social interaction and behaviour. Many also have learning problems and intelligence that is below average.

Children with Asperger syndrome have milder symptoms affecting social interaction and behaviour. Their language development is usually alright but they can have problems in certain aspects of language, for example, understanding humour. Their intelligence is usually above average. Some are skilful in memory, logic and creativity, eg in music, and pure sciences.

Children who have some, but not all of the features of autistic disorder and/or Asperger syndrome, are said to have a pervasive developmental disorder. Most have milder symptoms than autistic disorder but do not possess the good language and above average intelligence of Asperger syndrome.

Looking at the causes

Autistic spectrum disorder (ASD) can be due to primary or secondary factors. There is no medical condition in the former, which comprises 90% of ASD. A medical condition is thought to be wholly or partially responsible for the latter, which comprises 10% of ASD.

The conditions in secondary ASD are fragile X syndrome, tuberous sclerosis, and Rett syndrome.

Fragile X syndrome affects about one in every 3,600 boys and 6,000 girls, who have characteristic long faces, large ears and flexible joints. Tuberous sclerosis affects about one in 6,000 children, who have multiple, non-cancerous tumours all over the body. Rett syndrome affects about one in 20,000 girls who have ASD, and they have problems with physical movement and development.

Primary ASD is associated with genetic, environmental, neurological and psychological factors.

Although there is no specific gene identified, ASD is known to occur in families. If a child has ASD, there is about a 5% chance that another child born to the same parents will have ASD. If an identical twin has ASD, the chance of the other twin developing the condition is 60%.

The environmental factors associated with ASD are viral infection and maternal smoking during pregnancy, and the father’s age. Pregnant women exposed to rubella have a 7% chance of having an ASD child. The chance of pregnant women who smoke daily having a child with ASD is 40%.

First time fathers above 40 years of age are six times more likely to father a child with ASD.

Studies on neurological factors have focused on the brain’s amygdala, which acts like a switchbox between the cerebral cortex and the limbic system. The former processes sensory information and is responsible for all the brain’s higher functions like thought, language, and problem-solving, while the latter controls a person’s emotions.

The amygdala chooses the emotion to match the situation a person is in. Brain imaging studies suggest that connections between the cerebral cortex, amygdala and limbic system are altered in ASD.

Other studies have focused on mirror neurones which are thought to enable copying of the actions of others, eg an infant returns a mother’s smile. As the child grows up, the mirror neurones may be involved in the brain’s higher functions like language, learning, and recognition and understanding of others’ emotions.

Brain imaging studies have found that the response of mirror neurones is altered in ASD. This mirror neurone dysfunction may be responsible for the problems with language, social interaction and some aspects of learning in ASD.

The focus of research on psychological factors is the concept of “theory of mind” (TOM). TOM refers to a person’s ability to understand the mental states of others, ie the ability to see the world through another person’s eyes. It is believed that most children understand TOM fully by about four years of age. Children with ASD have a limited or non-existent understanding of TOM, which may explain their problems with social interaction.

Although there are reports of links between vaccines and autism, none have held up to scientific scrutiny. There is no conclusive evidence that any part of a vaccine or combination of vaccines causes autism. There is also no evidence that any material used to make or preserve vaccines play a role in the causation of autism.

Symptoms of ASD

The features of autism involve communication, social interaction and behaviours. Communication can be verbal or non-verbal, eg eye contact, smiling, pointing. The social interactions include holding a conversation and understanding how others feel and think. The behaviours are repetitive, and include repeating actions or words, play and obsession with routines.

Some features may be typical of ASD while others may be a delay in the child’s development.

Features are related to a child’s development and may appear as early as six to 18 months when the baby may not follow a gaze nor appear to recognise or respond to a voice, but there is awareness of other sounds. The baby does not “babble” and appears expressionless. The baby has little interest in the surroundings or rarely makes gestures like pointing or waving.

The features are more obvious as the child becomes older. Language and social interaction problems become noticeable, together with unusual behaviours. Speech development may be delayed, or there is none at all. Speech can also be monotonous and repetitive.

The child does play in an imaginative but repetitive way. There is limited or no awareness of people in their surroundings. They may form friendships with other children only to behave inappropriately.

Many ASD children exhibit repetitive physical behaviours, eg rocking back and forth or licking objects. They prefer strict routines, which, if disrupted, would lead to temper tantrums or even attempts at self-harm. They often dislike certain foods.

There is usually an improvement as the child begins school. However, those with severe ASD may find school stressful, which may trigger disruptive behaviour.

Although most older children improve their language skills, specific difficulties may remain, eg repeating words in a “parrot” fashion, inability to understand humour, or sarcasm. Their lack of understanding of social interaction often hampers their friendships with other children of the same age. They need strict routines.

Children with Asperger syndrome do well with subjects involving facts, figures and logic, but they may have problems with subjects requiring abstract thought, eg literature.

A parent who is worried about a child’s development would benefit from a consultation with his regular doctor who may carry out a brief screening test. This involves several questions and some assessment exercises with the child.

If the doctor suspects ASD, a referral will be made to a paediatrician, psychiatrist or psychologist who will carry out a detailed assessment, which would include a physical examination and other investigations.

When there is a diagnosis of ASD, it facilitates the parents understanding of their child’s condition and plans can be then instituted to help the child.

Managing the problem

There is no cure for autism; neither is there a single treatment for ASD. The objectives of management are to enhance learning and minimise its features.

There are several effective education and behavioural programmes. According to the American Academy of Paediatrics, “the principles and components of effective early childhood intervention in ASD include:

· Entry into intervention as soon as an ASD diagnosis is seriously considered rather than deferring until a definitive diagnosis is made;

· Provision of intensive intervention, with active engagement of the child at least 25 hours per week, 12 months per year, in systematically planned, developmentally appropriate educational activities designed to address identified objectives;

· Low student-to-teacher ratio to allow sufficient amounts of one-on-one time and small-group instruction to meet specific individualised goals;

· Inclusion of a family component (including parent training as indicated);

· Promotion of opportunities for interaction with typically developing peers to the extent that these opportunities are helpful in addressing specified educational goals;

· Ongoing measurement and documentation of the individual child’s progress toward educational objectives, resulting in adjustments in programming when indicated;

· Incorporation of a high degree of structure through elements such as predictable routine, visual activity schedules, and clear physical boundaries to minimise distractions;

· Implementation of strategies to apply learned skills to new environments and situations (generalisation) and to maintain functional use of these skills; and

· Use of assessment-based curricula that address:

1. Functional, spontaneous communication;

2. Social skills, including joint attention, imitation, reciprocal interaction, initiation, and self-management;

3. Functional adaptive skills that prepare the child for increased responsibility and independence;

4. Reduction of disruptive or maladaptive behaviour by using empirically supported strategies, including functional assessment;

5. Cognitive skills, such as symbolic play and perspective taking; and

6. Traditional readiness skills and academic skills as developmentally indicated.”

The management options include educational interventions, behavioural therapy and medicines.

The ideal educational intervention is to involve parents, teachers, psychologists and others to develop an individualised education plan that forms a structured framework for the child’s school experience.

Studies have shown that ASD children benefit from visual information. Speech and language therapy improves language skills and the child’s ability to interact socially. There are a variety of techniques that improve communication skills, eg listening and attention skills, as well as the ability to understand the social and/or emotional context of specific language and non-literal language.

Behaviour therapy reinforces appropriate behaviours and reduces inappropriate behaviours. Skills are broken down into small tasks and rewarded in a structured manner. Speech therapists, occupational therapists and physiotherapists have an important role in improving communication and interaction skills, adjusting tasks to match abilities and needs, and improving motor skills respectively.

There are no medicines that can cure ASD. But medicines are available to treat some of the symptoms, eg repetitive thoughts and behaviour, and aggressive behaviour. The selective serotonin reuptake inhibitors (SSRIs) – fluoxetine and paroxetine – which alter the brain levels of serotonin, a chemical which affects mood and behaviour, are used often.

Other medicines used include anti-psychotics, tricyclic compounds and anxiolytics. All these medicines are prescription items.

There is no evidence that complementary and alternative medicines are effective, and some may even be dangerous.

The outlook for ASD depends on its severity and the child’s intelligence. Those with mild to moderate ASD and average or above average intelligence often grow up to be independent adults with jobs and family. Those with severe ASD and below average intelligence are unlikely to be independent adults and would require care and assistance for the rest of their lives.

Source: Dr Milton Lum