Vitamin D and Respiratory Infections

A walk on the beach in Maui. (Dr. Noorali Bharwani)

A research article in the British Medical Journal (BMJ February 15, 2017) says vitamin D supplementation is safe and it protects you against acute respiratory tract infection.

The object of the study was to assess the overall effect of vitamin D supplementation on risk of acute respiratory tract infection, and to identify factors modifying this effect.

The researchers looked at the results of 25 eligible randomized controlled trials (total 11,321 participants, aged 0 to 95 years).

They found vitamin D supplementation reduced the risk of acute respiratory tract infection among all participants.

The article says acute respiratory tract infections are a major cause of global morbidity and mortality and are responsible for 10 per cent of ambulatory and emergency department visits in the USA and an estimated 2.65 million deaths worldwide in 2013.

Vitamin D deficiency is associated with many conditions, including bone loss, kidney disease, lung disorders, diabetes, stomach and intestine problems, and heart disease. Vitamin D supplementation has been found to help prevent or treat vitamin D deficiency.

Vitamin D, often called the sunshine vitamin, is mainly obtained from sun exposure of our skin. However, Canadians are not getting enough of sunshine vitamins. Supplements are necessary to obtain adequate levels because a person’s diet has minimal impact, says Osteoporosis Canada website (New Vitamins D Guidelines 2010).

“Canadians are at risk of vitamin D deficiency from October to April because winter sunlight in northern latitudes does not allow for adequate vitamin D production,” says Julie Foley, president & CEO of Osteoporosis Canada. She goes on to say that because vitamin D requirements for an individual may vary considerably depending on many factors, it’s very important to check with your physician about how much vitamin D you should be taking.

Vitamin D is essential to the treatment of osteoporosis because it promotes calcium absorption from the diet and is necessary for normal bone growth. Some research suggests it may also ward off immune diseases, infection and cancer.

How much vitamin D should you take each day?

The new guidelines recommend daily supplements of vitamin D 400 to 1000 IU for adults under age 50 without osteoporosis or conditions affecting vitamin D absorption. For adults over 50, supplements of between 800 and 2000 IU are recommended.

Coming back to our topic – Do vitamin D supplements help prevent respiratory tract infections?

An editorial comment in the British Medical Journal (15 February 2017) says clinically useful effect of vitamin D on respiratory infection remains uncertain despite hints in the new analysis mentioned earlier in this column.

The editorial goes on to say, “Eight trial level meta-analyses have examined this topic since 2012, with conflicting findings: three reported benefits and five no consistent benefits.” The editorial conclusion is… we need more trials to prove the point that vitamin D supplements protect against respiratory infection.

In the meantime there is no reason to avoid taking vitamin D everyday as indicated earlier. There is no doubt vitamin D is required for many more reasons than just preventing lung infection.

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Painkiller Use in Seniors with Non-Cancer Pain

Relaxation in Maui. (Dr. Noorali Bharwani)

An article in a newsletter published by the College of Physicians and Surgeons of Alberta (May 1, 2017) provides guidelines to physicians on safe prescribing of painkillers to seniors with non-cancer pain.

The article uses an example of John, a 78-year-old man who has experienced chronic low-back pain due to arthritis for several years, with gradual worsening over time. There is no indication John needs surgery.

John has several medical conditions that include mild cognitive impairment (problems with memory, language, thinking and judgment), high blood pressure, diabetes mellitus type 2, mild chronic renal impairment and falls.

His current medication regimen includes acetaminophen 500 milligrams (mg) when needed and naproxen 200 mg twice daily (over the counter supply). These painkillers do not relieve his pain. He wants a stronger medication.

As we know chronic pain is common in older adults. There are concerns regarding the potential adverse effects of painkillers in this population. But should we let them suffer? No. A person should be treated as a whole taking into consideration other medical problems.

Management of John’s pain includes appropriate assessment of the pain and other medical issues. That should include involvement of John’s family in the future management plan.

The article says, “Treatment-related goals should generally be directed toward improvements in function rather than in pain intensity as function-related goals are often more evident in patients with chronic pain.”

What kind of painkillers can we use safely?

Acetaminophen is the first line of treatment for older adults with mild-to-moderate pain. Acetaminophen at recommended doses is considered safe. Maximum recommended daily dose is 3,000 mg. Dose is lower if a person has liver disease or those who consume three or more alcoholic beverages daily. Acetaminophen should not be used if a person has severe liver failure.

Oral NSAIDs (non-steroidal anti-inflammatory drugs) are recommended to be used with caution and for the shortest time possible. This recommendation stems from the high risk of side effects, particularly with long-term use. It can adversely affect the stomach, heart and kidneys.

Topical NSAIDs, such as diclofenac gel, are generally preferred for localized musculoskeletal pain such as osteoarthritis.

Opioids (produces morphine like effect) use in older adults with chronic non-cancer pain has been associated with decreased pain intensity and improved function. However, there is a lack of data on long-term efficacy as existing studies have been only short-term. It is a narcotic and can cause confusion, increased risk of falls, fractures, hospitalization and mortality.

For mild to moderate pain, the recommendation is to use codeine or tramadol. Second-line opioid treatment for mild-to-moderate pain, and first-line for severe pain is morphineoxycodone or hydromorphone.

Antidepressants should be used in patients who have co-existing depression and pain.

Non-pharmacologic Management

This involves a psychologists and a social worker. They can be helpful in terms of teaching coping strategies, providing emotional support and accessing appropriate programs. A physiotherapist can help with flexibility, balance and endurance exercises.

Pain management in the elderly with multiple medical conditions is not easy but a team effort can do a lot to help and relieve suffering.

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Primary Progressive Aphasia

Casa Batlló, a building designed by Gaudí in Barcelona. (Dr. Noorali Bharwani)

Primary progressive aphasia is a rare nervous system syndrome. It is an acquired condition that affects a person’s ability to communicate.

An aphasic person cannot express himself or herself when speaking, has trouble understanding speech, and has difficulty with reading and writing or finding words.

Brain damage causes aphasia. This quite often happens after a stroke or head injury. It can happen if a person has a brain tumour or Alzheimer’s disease. It is important to remember primary progressive aphasia is not Alzheimer’s disease. In primary progressive aphasia the problem is a disorder of language with preservation of other mental functions of daily living for at least two years. Symptoms may get worse after that.

The effects of aphasia differ from person to person and can sometimes be eased by speech therapy. Most people affected by this condition can maintain ability to take care of themselves and pursue hobbies. In some instances a person can remain employed.

Primary progressive aphasia may present in a number of different ways but it commonly appears initially as a disorder of speech, progressing to a near total inability to speak in its most severe stage, while comprehension remains relatively preserved.

Symptoms begin gradually, often before age 65, and worsen over time. People with primary progressive aphasia have a difficult road ahead. They are fighting against a condition in which they will continue to lose their ability to speak, read, write, and/or understand what they hear. The illness progresses slowly.

Medically speaking, primary progressive aphasia is caused by a shrinking of the frontal, temporal or parietal lobes in the brain, primarily on the left side. The condition affects the language centers in the brain.

Who is at a higher risk of being affected by primary progressive aphasia? A person having learning disabilities and a person who has certain gene mutations – meaning that it may run in the family.

An individual who has aphasia should carry an identification card and obtain materials available from the National Aphasia Association (www.aphasia.org). This helps in communicating about the person’s condition to others.

Unfortunately, people with primary progressive aphasia eventually lose the ability to speak and write, and to understand written and spoken language. As the disease progresses, other mental skills, such as memory, can become impaired. Some people develop other neurological conditions. With these complications, the affected person eventually will need help with day-to-day care.

People with primary progressive aphasia can also develop behavioral or social problems as the disease progresses, such as anxiety or irritability. Other problems might include blunted emotions, poor judgment or inappropriate social behavior.

The diagnosis of the condition is based on history of worsening communication skills, changes in thinking and behaviour over one to two years. Besides physical examination a doctor will order several test including blood tests, speech and language tests, genetic tests, MRI, etc.

Unfortunately, primary progressive aphasia cannot be cured, and there are no medications to treat it. The good news is, some therapies, like speech and language therapy, may help improve or maintain the ability to communicate and manage the condition.

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Understanding Blood Calcium Levels

Mallorca (Majorca) is one of Spain's Islands in the Mediterranean. (Dr. Noorali Bharwani)

Calcium and vitamin D are the two most important nutrients for bone health. Calcium has many other important functions in the body.

Calcium is necessary for life.

In addition to building bones and keeping them healthy, calcium helps our blood clot, helps nerves send messages and helps muscles contract. About 99 percent of the calcium in our bodies is in bones and teeth.

Each day, we lose calcium through our skin, nails, hair, sweat, urine and feaces. But our bodies cannot produce new calcium. That is why it is important to get calcium from the food we eat. When we do not get enough calcium for our body’s needs, it is taken from our bones. This makes bones weak.

A natural source of calcium in our diet comes from milk and milk alternatives. It is important to drink milk everyday. Calcium is also found in dark leafy greens, legumes and canned salmon.

Role of parathyroid hormone

Excessive calcium (hypercalcemia) most commonly results from overactive parathyroid glands. These four tiny glands are each about the size of a grain of rice and are located on or near the thyroid gland. Certain types of cancer, other medical disorders, some medications, and excessive use of calcium and vitamin D supplements can also cause hypercalcemia.

Overactive parathyroid gland (hyperparathyroidism) can raise calcium levels. The role of the parathyroid hormone is to help maintain an appropriate balance of calcium in the bloodstream and in tissues that depend on calcium for proper function.

Hyperparathyroidism is often diagnosed before signs or symptoms of the disorder are apparent. When symptoms do occur it is because of damage or dysfunction in other organs due to high calcium levels in the blood, urine, or too little calcium in bones.

Hyperparathyroidism can cause a wide variety of symptoms. It can make bones fragile (osteoporosis), create kidney stones, increase urination, cause abdominal pain, weakness, depression and forgetfulness. It can also cause aches and pains, nausea, vomiting or loss of appetite.

When your calcium levels are low, your parathyroid glands secrete parathyroid hormone to restore the balance. Parathyroid hormone raises calcium levels by releasing calcium from your bones and increasing the amount of calcium absorbed from your small intestine. Parathyroid hormone also acts on the kidneys, resulting in decreased excretion of calcium.

The physiology and balancing acts of calcium, phosphorus, vitamin D and parathyroid hormone is very interesting and not easy to comprehend.

To summarize:

Bones play an important role in blood calcium levels, which must be maintained within narrow limits to maintain bodily functions.

Bones are the major storage site for calcium. The movement of calcium into and out of bone helps to maintain blood calcium levels.

Parathyroid hormone and calcitonin also help regulate blood calcium levels.

Parathyroid hormone promotes the absorption of calcium by the small intestines, which also increases blood calcium levels.

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Stroke Misdiagnosis in Young Adults on the Rise

Piazza dei Miracoli (English: Square of Miracles), formally known as Piazza del Duomo (English: Cathedral Square), is a walled 8.87-hectare area located in Pisa, Tuscany, Italy. (Dr. Noorali Bharwani)

A 2009 study by the Department of Neurology and Stroke Program at Wayne State University/Detroit Medical Center found that among 57 young stroke victims, one in seven were given a misdiagnosis of vertigo, migraine, alcohol intoxication, seizure, inner ear disorder or other problems – and sent home without proper treatment.

While the majority of strokes strike people over the age of 65, the incidence of strokes in individuals 50 and younger is on the rise. Because people associate stroke with the elderly, symptoms in younger victims can often be missed or dismissed – even by medical professionals.

What are the signs of stroke?

Recognizing the signs of stroke can be the first step to getting correct treatment. Experts recommend you use the mnemonic device FAST.

Face: is it drooping?

Arms: can you raise both arms?

Speech: is it slurred or jumbled?

Time is of the essence: to call 9-1-1 right away.

How can you be diagnosed and treated early?

For a good outcome early intervention and treatment is important.

A person has symptoms, the paramedics are called and the person is brought to the hospital. The ER physician does clinical examination and investigations and comes to a diagnosis. All this should not take more than one hour.

Once the diagnosis is made the standard of treatment is administration of medication called tPA (tissue plasminogen activator) intravenously. When tPA is promptly administered, it can save lives and reduce the long-term effects of stroke. It needs to be used within three hours of having a stroke.

According to Alberta Health Services, Alberta’s stroke treatment is now reported to be among the fastest in the world. Alberta’s quality improvement program cuts time for life saving drug treatment from 70 to 36 minutes. A similar effort in the United States saw average door-to-needle times in participating hospitals drop from 74 minutes to 59.

The accepted benchmark has been to treat patients within 60 minutes of their arrival at the hospital. The Grey Nuns Hospital in Edmonton currently holds the provincial record with the fastest door-to-needle time – six minutes.

The medication (tPA) was introduced 20 years ago. But the results are not perfect. Although tPA is successful in recanalyzing the blocked artery in up to 78 per cent of cases, this rate of success is dampened by a high rate of acute repeat occlusion leading to an ultimate rate of 33 per cent partial and 30 per cent full recanalization.

Doctors are working on newer methods to treat stroke patients. Now doctors are able to pull a clot from the brain of patients while they are having a stroke. It is called an endovascular procedure or a mechanical thrombectomy. The procedure should be done within six hours of acute stroke symptoms. The entire procedure takes about 10 minutes. This treatment is not available in all centers across Canada.

The message is clear. Whether the patient is young or old, for the best possible results, it is important to identify stroke symptoms and seek treatment immediately.

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Important Things to Know About CPR (Cardio-Pulmonary Resuscitation)

Sunrise at Haleakala Volcano Summit in Maui, Hawaii. (Dr. Noorali Bharwani)

“Bystander CPR is the most important predictor of survival from cardiac arrest,” says an article in the Canadian Medical Association Journal (CMAJ January 9, 2017).

The article is titled “Five Things to Know About Cardio-pulmonary Resuscitation.” Here is the summary.

1. Chest compressions – importance of fast pushes

Chest compressions during CPR should be fast pushes. In adult patients with out-of-hospital cardiac arrest, a large multicentric study has shown patient survival to hospital discharge was highest when compressions were between 100 and 120 per minute.

2. During the use of a defibrillator – importance of peri-shock pauses

During cardiac arrest the heart needs to be shocked with a defibrillator. To do this chest compression has to stop for a brief moment. This is called peri-shock pauses. Peri-shock pauses should be limited to improve survival. High priority is given to minimizing interruptions for chest compressions. It is recommended that total pre-shock and post-shock pauses in chest compressions be as short as possible.

Studies have shown survival is higher for those patients who received pre-shock pauses of less than 10 seconds and total peri-shock pauses of less than 20 seconds during CPR. Peri-shock pauses should be minimized during CPR by performing compressions while the defibrillator is charging.

3. Interrupted or continuous CPR strategy?

Bystander CPR is the most important predictor of survival from cardiac arrest. Any interruptions in chest compressions are associated with reduced blood flow and worse survival.

For this reason, and because ventilation (mouth to mouthing breathing) is a difficult skill to acquire for those who are not health care professionals, the guideline update recommends that members of the public provide uninterrupted continuous chest compressions.

Trained rescuers should provide 30 chest compressions that are interrupted by no more than 10 seconds to provide two ventilations (mouth to mouth breathing).

4. Role of medications during cardiac arrest

Should we use vasopressin or epinephrine during resuscitation? The aim is to improve return of spontaneous circulation and improve survival.

Vasopressin is a hormone. Its two primary functions are to retain water in the body and to constrict blood vessels to raise blood pressure.

Epinephrine, also known as adrenaline, is a hormone. It plays an important role in the fight-or-flight response of the body by increasing blood flow to muscles, output of the heart, pupil dilation, and blood sugar. As a medication it is used to treat a number of conditions, including anaphylaxis, cardiac arrest, and superficial bleeding.

The CMAJ article says vasopressin offers no advantage over epinephrine in cardiac arrest.

There is limited evidence to suggest that vasopressin and epinephrine can improve return of spontaneous circulation. Because simplicity is important during resuscitation efforts, the guideline update specifically recommends that epinephrine be administered as soon as possible following onset of cardiac arrest.

5. Maintain patient’s temperature during cardiac arrest

A target temperature should be maintained in the post-cardiac arrest period.

All adult patients who are comatose with return of spontaneous circulation following cardiac arrest should receive targeted temperature management. The guideline update recommends selecting and achieving a single target temperature between 32°C and 36°C, which should be maintained constantly for at least 24 hours.

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Women with Breast Cancer Can Modify Their Lifestyle to Improve Prognosis

Sunrise at the World's Tallest Tepee, Medicine Hat, Alberta. (Dr. Noorali Bharwani)

“Although more than 90 per cent of patients with breast cancer have early stage disease at diagnosis, about 25 per cent will eventually die of distant metastasis,” says an article in the Canadian Medical Association Journal (CMAJ February 21, 2017).

Women with breast cancer would like to improve their prognosis and live long. Making positive lifestyle changes can improve long-term prognosis and be psychologically beneficial, since the feeling of loss of control is one of the biggest challenges of a cancer diagnosis.

So which lifestyle changes can be recommended to patients in addition to standard breast cancer treatments?

The CMAJ article reviews the role of lifestyle factors, particularly weight management, exercise, diet, smoking, alcohol intake and vitamin supplementation, on the prognosis of patients with breast cancer. Here is the summary.

Weight management

Weight gain during or after breast cancer treatment increases the risk of recurrence and reduces survival, irrespective of baseline body mass index (BMI). Patients who are obese or overweight at breast cancer diagnosis have a poorer prognosis. So lose weight.

Physical activity

Physical activity can reduce breast cancer mortality by about 40 per cent and has the most powerful effect of any lifestyle factor on breast cancer outcomes. At least 150 minutes per week (about 30 minutes a day) of physical activity is recommended, but less than 13 per cent of patients with breast cancer attain this. So exercise more.

Diet

Western-style diets (high in processed grains, processed meats and red meat) and prudent diets (high in fruits, vegetables, whole grains and chicken) have similar rates of breast cancer recurrence. Diets rich in saturated fat, especially from high-fat dairy products, may be associated with increased breast cancer deaths. Soy products have not been found to increase breast cancer recurrence and may actually reduce it. Eat less and stop eating fatty food.

Smoking

Recent evidence has shown a strong association between a history of smoking and breast cancer mortality. Women who quit smoking after diagnosis of breast cancer have higher overall survival and possibly better breast cancer–specific survival. So quit smoking.

Alcohol intake

Findings are too inconsistent to conclude that alcohol consumption affects breast cancer outcomes. However, limiting alcohol consumption to one or fewer drinks per day reduces the risk of a second primary breast cancer.

Vitamin supplementation

Moderate increases in dietary vitamin C or oral supplementation may reduce breast cancer mortality, but randomized trials are needed to confirm these findings. Vitamin E supplementation is not associated with breast cancer outcomes. Low levels of vitamin D at diagnosis have been associated with an increased risk of breast cancer deaths. However, randomized trials are needed to determine whether supplementation improves prognosis. One multivitamin a day and Vitamin D 2000 units a day is good for your health.

So the message is clear – make positive life-style changes like exercise more, lose weight and eat healthy. And keep smiling.

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