key: cord-0003423-6h34gp3x authors: Mughal, Faraz; Chew-Graham, Carolyn A; Saad, Ahmad title: ‘Hajj: what it means for general practice’ date: 2018-04-18 journal: BJGP Open DOI: 10.3399/bjgpopen18x101493 sha: e0668c4b793d0cad26639b070819334a94648123 doc_id: 3423 cord_uid: 6h34gp3x nan The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs. The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2 This is important as delayed treatment has unfavourable consequences. 1, 3 We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture. This could present a new indication for GP ultrasound. A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting. He immediately had difficulty walking and 3 hours later consulted an on-call GP. Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found. Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze. Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact. The patient was advised to elevate the foot and wait 2 weeks for improvement. Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient. Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination. Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon. Simmonds-Thompson's test was clearly positive. The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon. A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound. The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen ( Figure 1) . Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap ( Figure 2 ). Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'. Tromsø Hospital serves a large area with a population of approximately 160 000. Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture. GP-confirmed complete Achilles tendon rupture using pocket-sized ultrasound: a case report Introduction The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs. The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2 This is important as delayed treatment has unfavourable consequences. 1, 3 We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture. This could present a new indication for GP ultrasound. A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting. He immediately had difficulty walking and 3 hours later consulted an on-call GP. Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found. Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze. Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact. The patient was advised to elevate the foot and wait 2 weeks for improvement. Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient. Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination. Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon. Simmonds-Thompson's test was clearly positive. The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon. A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound. The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen ( Figure 1) . Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap ( Figure 2 ). Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'. Tromsø Hospital serves a large area with a population of approximately 160 000. Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture. The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs. The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2 This is important as delayed treatment has unfavourable consequences. 1, 3 We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture. This could present a new indication for GP ultrasound. A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting. He immediately had difficulty walking and 3 hours later consulted an on-call GP. Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found. Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze. Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact. The patient was advised to elevate the foot and wait 2 weeks for improvement. Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient. Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination. Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon. Simmonds-Thompson's test was clearly positive. The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon. A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound. The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen ( Figure 1) . Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap ( Figure 2 ). Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'. Last summer our small medical team visited the Calais 'Jungle'. Since that time much has changed and the camp is being demolished and by the time this article is read, it will probably be long gone. Some youngsters are finally being brought to the UK under the 'Dubs' amendment. However, once this camp is cleared it will not solve the ongoing flight of refugees from war torn areas: other camps are already appearing. A young Afghan man caught his finger on a sharp point while trying to cross a barbed wire fence. The finger was partially degloved. He attended the local hospital, where they placed a few sutures, but now, 2 weeks later, the skin is necrotic and the underlying tissue looks infected. He is in danger of losing his finger. A middle-aged Sudanese man has been having rigors and is generally unwell. He says it is similar to when he last had malaria. A young Ukrainian woman complains of lower back pain and urinary frequency. The paths of these three people may never have crossed; yet here they are, denizens of the Calais Jungle. They turn up to a makeshift primary care 'clinic' that we set up in the heart of the unofficial refugee camp one weekend in July 2016. With only basic medical supplies, we are immediately challenged by what we see. How can we arrange secondary care for the young Afghan in danger of losing his finger? We try to persuade him to return to the original local hospital, but he is reluctant. It was not a good experience for him the first time round. With the other two patients, it is easier. They can attend the Salam clinic run by a local association during weekdays. Later, we receive word that malaria has been confirmed in our Sudanese patient. More people arrive, presenting with scabies, rat bites, tinea, chest infections, and wheezing from inhaling smoke from fires lit to cook and keep warm in their tents at night. We examine a severely malnourished 2-year-old boy. We meet several of the camp's 600 unaccompanied children, at grave risk of sexual exploitation. We learn that there is inadequate safeguarding in place to protect them. A young Eritrean man comes in worried about his eye. He has sustained direct ocular trauma from a rubber bullet, and will never see normally again out of that eye. We see haematomas from police batons, and hear about children being exposed to tear gas again and again (Figure 1 ). These are no ordinary patients. They have travelled far from home to escape war, poverty, and misery. They have endured personal odysseys to get here, experienced untold hardships, and suffered unimaginable privations. Many have survived the loss of their families, torture, and rape. Their journeys over, for the moment at least, they must make their homes in the Calais Jungle. Their new shelters are in many cases mere tarpaulin covers, and their new beds just rugs on the ground. They own next to nothing. There is little for them to do, besides use their ingenuity to cross the English Channel in search of a better life. They are vulnerable to exploitation, crime, injury, and disease. Potentially violent clashes with local police, with other ethnic groups resident in the Jungle, or local far Hajj is the fifth pillar of Islam and is described in the Quran, as Almighty God says: 'Pilgrimage to this House is an obligation by God upon whoever is able among the people' (3:97). 3 It is obligatory for every Muslim adult with mental capacity to perform the Hajj once in a lifetime, if reasonably able to do so without excessive hardship. The pilgrimage lasts 5 days, although pilgrims usually travel for longer. The Hajj occurs 10 days earlier each year (adhering to the lunar calendar), and in 2018 it is estimated to start around the 19 August. The word 'Hajj' means to travel to the holy city of Mecca with the intention of performing certain rituals and visiting certain places at a specific time of the year. The actions of Hajj are specified and detailed in the books of jurisprudence. During Hajj days, millions of pilgrims move and worship within a small area of around 12 kilometers, in a display of dedication, universal brotherhood, and gratitude. An accepted Hajj brings reward no less than Paradise, as related from the Prophet Muhammad himself. 4 The rites of Hajj are physically demanding, involving travelling in heat and among large crowds, in addition to engaging in demanding and draining physical rituals, which are lengthened by the masses of pilgrims, and occur in confined spaces (Hajj tents at Mina can hold up to 100 pilgrims each). Hajj is the largest annual gathering of people globally (1.86 million in 2016), and thus one can appreciate the challenge of performing individual rites among such a mass gathering. 5 Hajj is a deeply profound and spiritual act of worship that Muslims comprehensively prepare for, and is unique in that it involves the use of one's body and wealth. Some spend years seeking the financial means to travel, and others fulfil rights of deceased relatives, through performing Hajj on their behalf. Pilgrims from all countries, whether a chief executive officer from the US or a farmer from Afghanistan, stand shoulder to shoulder in prayer, undertaking the Hajj rites, covered in sheets of cloth signifying equality and instilling humility in front of God. In 2017, Saudi Arabia's Ministry of Health declared that there were 643 deaths occurring at Hajj. Of these deaths, 18% were attributed to heart failure, 15% to myocardial infarction, 3% sepsis, and 2% heatstroke. 6 Pilgrims may present to health centres with a variety of illnesses; respiratory disease accounts for 61% of presentations, musculoskeletal problems 18%, dermatological 15%, and gastrointestinal 13%. One fifth of patients present with multiple problems. 7 Physical health status is a condition considered as part of one's ability to perform Hajj according to Shaykh Nur Al-Din 'Itr, a scholar of international authority on Hajj. 8 If a person has permanent disability, significant paralysis, or would experience difficulty travelling due to old age, an individual can be chosen to deputise to perform Hajj on their behalf. 8 In temporary medical illness, a deputy cannot be selected; rather, one needs to wait until the medical condition improves to be deemed fit to perform Hajj by a clinician. Clinicians should know that patients may still travel against medical advice, choosing to trust and rely on God. However, accurate medical advice must be given so that an informed decision can be made. Preparation . A progressive build-up of physical activity prior to the pilgrimage is advisable, to condition the body and mind for the physical and mental demands of the pilgrimage. . Walking a few miles a day would be sufficient preparation to optimise exercise tolerance. . Transport has improved considerably, with efficient train and bus routes now available along parts of the pilgrimage course for those who find walking long distances difficult. Vaccinations 9 . Anyone travelling for Hajj should be adequately immunised. . A certificate of the quadrivalent meningococcal ACWY vaccine is required for visa attainment. . Those at high risk should be offered the influenza vaccine. Pneumococcal, typhoid, hepatitis A, hepatitis B, MMR, and polio immunisations should all be up to date. . Women may wish to delay their menses using medication. Medication and list of drugs 10 . Pilgrims with chronic disease must carry sufficient medicines for the journey and prescription details. A diagnostic summary small enough to fit into a travel pouch would enable a rapid assessment in the 141 established primary medical centres or 24 hospitals within the immediate vicinity of the Hajj. . Pilgrims with diabetes mellitus need to be advised to eat regular meals, check blood sugars often, and maintain medication compliance. . If on insulin, they will need a letter for transport of needles and syringes through airports. . They should be reminded about hypoglycaemic awareness, and should carry appropriate foods when performing the pilgrimage rites to prevent exertion-induced hypoglycaemia. . Good footwear is important, however the type must be religiously permitted according to the pilgrim's school of Islamic law. . Blistering heat in the day is common while walking, and thus feet are prone to blisters. If bare-footed (not recommended) then the risk of infection, burns, and cuts, especially in pilgrims with diabetes, is high. Heat . The heat during Hajj (>40 degrees celsius in summer months) carries risks of heat exhaustion and heatstroke. . To avoid this, patients should be reminded of simple practical measures: avoiding prolonged exposure to the sun, drinking and carrying plenty of fluid, using unscented sunscreen, and keeping one's head covered where possible (men cannot directly cover their heads during Hajj, but can use a white umbrella to deflect sunlight). . During the Hajj, men may get their head shaved and women may shorten their hair. . The razors used by street barbers may not always be clean and thus pilgrims should insist on a new razor blade, to reduce the chance of blood-borne virus exposure (for example, HIV, and hepatitis B and C). Box 1 highlights advice that should be given prior to the patient embarking on the Hajj journey. The mass gathering of Hajj makes susceptibility to airborne disease likely. The spread of respiratory tract infections is common, and on return from Hajj, the primary care doctor should consider tuberculosis, atypical pneumonia, and Middle East respiratory syndrome coronavirus in patients with flulike symptoms. 2, 7 Primary care clinicians need also to be vigilant for symptoms or signs of hepatitis, malaria, meningitis, and hydatid disease in patients presenting with acute illness on returning from Hajj. 9 Clinicians can signpost patients to detailed online information for Hajj, but there are no readily accessible patient leaflets that summarise comprehensive health advice for those who intend to travel for Hajj. 1,2 These could be administered in primary care consultations and should be available in different languages. The present authors feel this should be a priority for NHS England, Public Health England, and the Muslim Council of Britain. Hajj is the largest annual mass gathering event internationally. 5 It is therefore important for primary care practitioners to be familiar with how to appropriately advise patients intending to travel for the pilgrimage. Patients with complex health needs and polypharmacy must be counselled adequately on their fitness to travel for the Hajj. Freely submitted; externally peer reviewed. Health and travel advice for Hajj pilgrims Latest travel health advice for Hajj and Umrah pilgrims published The clear Quran: a thematic English translation Kingdom of Saudi Arabia Kingdom of Saudi Arabia. Statistical yearbook 1437 Pattern of diseases among visitors to Mina health centers during the Hajj season, 1429 H (2008 G) Itr N. al-Hajj wa'l 'Umrah fi'l Fiqh al-Islami [Hajj and Umrah in Islamic jurisprudence] (in Arabic). 5th edn. Al-Yamamah: Beirut Hajj: journey of a lifetime Saudi Arabia has several strategies to care for pilgrims on the Hajj