The Doctor’s Dogs: Gracey, Ninja and Baskerville

On 16.2.2016 afternoon, I felt obliged to bring my 3 dogs for their walk in the park, as Mummy was down with flu.  Their usual walk time is around 6 pm and they were all glared at me restlessly as they looked forward to their walk. All the 3 dogs can understand some English and they love to sit on their allocated 3 individual rows of chairs, especially if they are asked to.

GRACEY:

Gracey is the “queen”.  She is always in charge and the other 2 don’t dare to challenge her even once! This is possibly because she is the adult dog when the other 2 were still puppies. She also has the killer instinct and never hesitates to sink her fangs into the neck of the other 2 since they were puppies. She is now 3½ years old. I bought her with her brother named “Champion”.  On 13.1.2013, Champion passed away after being rolled over by Mummy’s car.  Champion was very playful and rather indiscriminate.  He was probably playing with the tyre when my wife drove in slowly after sending me off to the airport. He was yellow, with fluffy ears and black patch on the nose and the distal part of his tail.  He was my son’s favourite dog and apparently he brought him to his room as well.  The mummy called the son in London to ask for instructions in a desperate attempt to revive him.  I buried him in the back garden when I came back.

Gracey is ever so dainty but very gentle and sure footed.  We had a steady walk in the park with all the birds chirping away but her gentle physique does not prevent her from showing her  killer instinct. I really have to pull her away when there are other dogs in the park! 

NINJA:

Ninja is the dashing and handsome persistent boy. He can stand up and quickly plant a kiss on my daughter’s cheek. When I wash my clothes, he will stand up to check on my work!  His front paws are like hands which can open a partially closed gate or door. Going for a walk with him in the park is like riding a horse as he gallops around. The neighbour’s white dog is always aggressive with him.  I made a wrong turn and almost walked into the male dog who followed us at least 2 metres with a menacing stance.  Ninja also loves Ping-Pong cream crackers. He will dash for them at the back door and take them away to a corner to sniff and savour the biscuits with his 2 front paws.  Ninja is the most energetic dog in the park. I always wonder how he has so much urine as to mark on some many trees and bushes!

BASKERVILLE:

I chose Baskerville when we bought the 2 puppies from the 10^th Mile market.  He looks big (thought to be the “king” of the puppies).  As he grew up, I realized that he just looks big because he has fluffy hair. Although he is supposed to be the brother of Ninja, he has quite a different temperament.  He  takes time to learn but he eventually gets there. He is also not trusting and even barks at my other son on and off.  He loves to take a dip in the bath tub, especially when no one is looking.  He also loves to do some sun bathing as if his ancestors came from a cold country. He has a rather stubborn confidence and does not easily give in to harassment from Ninja. A small female dog in the neighbourhood obviously has a fatal attraction to Baskerville as she often comes to the gate and wagging tail & back vigorously!  Baskerville does have a mind of his own and he is the only dog who refused to come back to the house when I told him so. He stood still and waited for my foot steps to make a few steps in the direction of the house before he finally gave up and followed me back.  Baskerville is the most hardworking dog. I noticed that he patrols the house regularly and at the slightest hint of intrusion, he barks the loudest and longest!

DOG THERAPY:

My daughter once said that “if you need love, just get a dog!”. Their loyalty is unweaving and they  never forget. 

Attached photos to show what I meant!

by Dr Clarence Lei Chang Moh, 20 Feb 2016

URO ONCOLOGY for medical students on 28 January 2016

URO-ONCOLOGY     

Dr Clarence Lei Chang Moh, FRCS Urol, Consultant Urologist,  clarencelei@gmail.com

           

HAEMATURIA

Painless gross haematuria can be a symptom of kidney or bladder cancer.  Therefore, it is usually investigated with an Ultrasound scan and CTU (CT urogram) to see the upper tract and a cystoscopy to see the bladder.  Painful gross haematuria is commoner and may be caused by stones or infection.  Other sources of gross haematuria include BPH, benign prostatic hyperplasia (usually > 55 years of age), glomerulonephritis (usually young) and vascular malformations. Radiocontrast is contra-indicated  if there is renal failure or a strong history of allergy.

The main tumours of the urinary system are:

1)  Kidney:      adenocarcinoma, Wilm’s tumour (the later in children).

2)  Bladder:     transitional cell tumour, the commonest tumour of the urinary system.

3)  Prostate:    adenocarcinoma.

4)  Testis:        teratoma, seminoma.

5)  Penis:         squamous cell carcinoma.

KIDNEY:

Adenocarcinoma (or RCC, renal cell carcinoma, usu CCC, clear cell carcinoma)

Presentation:             Gross painless haematuria; renal mass.

Investigations:           CT shows a SOL.

Ultrasound to distinguish solid tumour from cyst, see IVC and renal vein invasion by tumour thrombus (feature of RCC).

CXR

CT scan to see para-aortic lymph nodes.

Management:            Surgical removal is currently the only hope of cure.  This is possible in locally confined disease; embolus present in the renal vein/IVC can be removed with the cardiac surgeon.  Chemotherapy and radiotherapy are not effective. Immunotherapy (e.g. interleukin-2) and kinase inhibitors (sorafenib, sunitinib) is promising  for metastatic disease.

In Wilm’s tumour, chemotherapy has important role and hence, important to manage with paediatric oncologist.

                       

BLADDER:

Clinically commoner then cancer prostate in Malaysia.  Usually TCC (transitional cell carcinoma). Almost ALL tumours in the bladder are TCCs.

Presentation:             Gross painless haematuria; suprapubic mass rarely (i.e. unusual to have clinical signs).

 

Aetiology:                  Smoking increases risk 4 x

                                    An ‘industrial disease’ where aromatic amines were used e.g. in rubber/dye industries.

Investigations:           (1)   CTU, to see upper tract

(2)     Ultrasound, to see any big tumour in bladder.

(3)     Cystoscopy – commonly a papillary growth.

(4)     EUA, to stage locally.

(5)     CT abdomen and pelvis, to stage

Management:                        Depends on stage and grade:

(a)     NMIBT, non muscle invasive bladder tumour – transurethral resection (TURBT, transurethral resection bladder tumour). May reduce recurrence with immediate intravesical Mitomycin C /BCG and cessation of smoking.

(b)     Bladder Muscle Invasive – radical surgery to remove bladder and urinary diversion.  Radiotherapy if not fit for surgery.  5-year survival: 50%. Grade 3 TCC especially if associated with CIS (carcinoma in situ) may be treated with radical surgery if the patient is agreeable.

(c)     Advanced (locally fixed, node positive or metastatic) – palliative chemotherapy.

Note:  T.C.C. may be found occasionally in other parts of the urothelium e.g. ureter and renal pelvis.

PROSTATE:

Radical differences in incidence (e.g. very low in Japanese) may be related to genetics and diet. 

Presentation:             If early, detected by blood test, PSA (prostatic specific antigen).  If advanced, urinary retention, bone pain from secondaries.

Investigation:                        Biopsies (transrectal ultrasound guided)

X-ray (pelvis) osteosclerotic lesions (Ca prostate is the commonest cause of such lesions).

CT Pelvis and/or laparoscopy to stage (lymph nodes)

Bone Scan.

Management:            (a)  Localised disease:  radical prostatectomy (or radiotherapy) if  life expectancy > 10 years as disease may be slow growing. Robot assisted laparoscopic radical prostatectomy (RALP) is the preferred treatment for localized disease. In low grade low volume disease with slow PSA doubling time, active surveillance may be an option.

(b)     Advanced disease (local invasion, node +ve, metastatic) palliation by androgen deprivation.  This may be surgical (orchidectomy) or medical (injection LHRH analogue 3 monthly). Localised bone pain can be treated with radiotherapy.

TESTIS:

Presentation:             Testicular mass – any SUCH MASS SHOULD BE CONSIDERED MALIGNANT UNLESS PROVEN OTHERWISE.

Aetiology:                  A maldescended testis has a higher incidence (5%), patients with such a history should do TSE (testicular self examination) monthly; usu. a cancer of young men.

Investigation:            Ultrasound – to determine that the swelling is actually testicular (and not, e.g. a hydrocele).

Tumour markers – alpha-fetoprotein, beta-HCG (raised in teratoma).

Management:            Radical orchidectomy as biopsy – inguinal route mandatory to control vascular pedicle to prevent tumour embolisation.  When diagnosis confirmed, to stage tumour with CXR, CT scan abdomen and chest.

CHEMOTHERAPY IS THE MAINSTAY OF TREATMENT AND OFTEN CURATIVE.

PENIS:

Presentation:             Penile ulcer and growth, often in an advanced state although the penis is an easily visible and often used organ.

Aetiology:                  Circumcision in infancy gives complete immunity.

Investigation:                        Biopsy (including inguinal lymph nodes if these are enlarged).

Management:            Surgery, chemo and radiotherapy.

23.10.01; updated 28.1.2016

Urolithiasis lecture at Unimas 2016