Author: noorali

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Diarrheal Diseases are a Scourge to Humanity

Diarrheal diseases have been a scourge to humanity throughout recorded history all over the world. “Infections are estimated to account for three to four billion cases of diarrhea each year, and up to 4.3 million deaths in children under the age of five years,” says an article in the Canadian Journal of Gastroenterology.

Poor countries bear the biggest brunt but developed countries are not spared.

Diarrhea means loose, watery stools and abdominal cramps. Frequency of bowel movements may vary in each case. It may be acute in nature. That means it may last only a few days. It is unpleasant and from time to time almost everyone experiences it.

Most common causes of acute diarrhea are due to infections. Viruses like rotavirus and adenovirus are common examples in young children. Direct contact easily spreads viral diarrhea.
Parasites such as giardia and cryptosporidium can cause diarrhea. Certain bacteria like campylobacter, salmonella, shigella and E. coli can cause diarrhea. The source of infection is contaminated food or water.

Acute diarrhea can also be side effect of many medications, particularly antibiotics. Antibiotics related colitis has been discussed in these columns before. Traveller’s diarrhea can occur in 20 to 50 percent of travellers to tropical countries. Eighty percent of traveller’s diarrhea is due to bacterial infection.

Chronic diarrhea lasts much longer than acute diarrhea. Diarrhea lasting four weeks would probably be considered chronic but six to eight weeks would provide a better distinction.

The prevalence of chronic diarrhea in developed countries seems to be approximately five percent. It can be a sign of a serious disorder like chronic infection, inflammatory bowel disease or poor absorption of nutrients (malabsorption). It may be due to a less serious condition such as irritable bowel syndrome.

Other causes of diarrhea are lactose intolerance (a sugar found in milk and milk products), artificial sweeteners (sorbitol and mannitol), found in chewing gum and other sugar-free products can cause diarrhea.

There are many more causes of chronic diarrhea. They cannot all be mentioned here. To name a few: dumping syndrome, celiac disease, chronic pancreatitis, antacids, alcohol use and diabetes.

In one study, 30 percent of the patients a definite cause of diarrhea was found. In 20 percent of the patients the cause was found to be in laxative and diuretic abuse. In 50 percent of the patients no specific diagnoses was made. They were given the diagnoses of “functional” or “idiopathic” diarrhea.

Most significant complication of diarrhea is dehydration – as suggested by excessive thirst, dry mouth, little or no urination, severe weakness, dizziness or lightheadedness. This can be dangerous especially in children and the elderly. Bloody diarrhea with fever can be dangerous too. One should seek immediate medical help.

Sometimes diarrhea is only an inconvenience. Sometimes it can be life threatening. Sometimes it can be prevented by good preventive measures like washing hands and avoiding potentially contaminated food and water. Sometimes there is not much you can do to avoid it – especially in cases like ulcerative colitis, Crohn’s disease and other medical conditions.

If there is a change in your bowel habit then seek medical attention. It may save your body and your butt lot of grief.

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What do we know about Clostridium difficile colitis?

Few years ago, there was an outbreak of Clostridium difficile (C. difficile) colitis in Canada, the United Kingdom and the United States which killed many patents in hospitals and nursing homes.

C. difficile is a bacterium common in the environment. It is transmitted from person to person by fecal-oral route. That means we ingest food which is contaminated by somebody who handled that food. It comes down to poor hygiene. Remember, hand washing?

The bacterium, in the form of a spore, settles down in the colon (large bowel) and waits there to create trouble. A spore is highly resistant to desiccation and heat and is capable of growing into a new organism. Normally, mature colonic bacterial flora in a healthy adult is generally resistant to C. difficile colonization.  However, if the normal colonic flora is altered, for example, by taking antibiotics, resistance to colonization is lost. If that happens, then there is overgrowth of C. difficile.

What happens then? You may have no symptoms but become a carrier and spread it around if you do not maintain good hygiene. You may have symptoms like watery diarrhea to life- threatening pseudo-membranous colitis. Pseudo-membranous colitis is an inflammatory condition of the colon, also called antibiotic-associated colitis or C. difficile colitis that occurs in some people who have received antibiotics.

Typical clinical features include watery diarrhea, lower abdominal pain and systemic symptoms such as fever, anorexia, nausea and malaise. In severe cases, the colon may perforate, necessitating removal of the colon.

The severity of the colitis depends on many factors: the subset of bacteria (pathogenecity), use of antibiotics, advanced age, underlying illness, poor immune systems or use of chemotherapy. The incubation period from ingestion of C. difficile to onset of symptoms has not been determined. However, time from antibiotic exposure to onset of symptoms has been as short as one day to as long as six weeks or even longer.

You may wonder if you are carrying C. difficile in your colon. The incidence of C. difficile carriage is about one to three per cent among healthy adults. It is higher among hospital employees and those working with susceptible patients. The rate increases to about 20 per cent with antibiotic use. As many as 31 per cent of high- risk patients in hospital are colonized with C. difficile, with only a subset becoming symptomatic, says an article in the Canadian Medical Association Journal (CMAJ).

 Pathogenic strains of C. difficile produce toxins, conventionally identified as A and B. Diagnosis of colitis is generally based on the detection of toxin A or B in stool filtrates. The processing of a single stool specimen for toxin detection at the onset of symptoms is generally sufficient to establish the diagnosis. The results are usually available in 48 hours. . There is no value to testing stools of asymptomatic patients, including follow-up for “test-of-cure,” unless an outbreak is being investigated (CMAJ).

Treatment typically involves cessation of the offending antibiotic, initiation of oral metronidazole or vancomycin therapy, and fluid replacement. Oral metronidazole therapy (250 mg 4 times daily or 500 mg twice daily) given for 10–14 days is recommended as the initial treatment of choice. Vancomycin (125 mg orally 4 times daily for 10–14 days) is the recommended second-line therapy.  

Unfortunately, recurrent C. difficile diarrhea occurs in about five to 20 per cent of patients after treatment with either metronidazole or vancomycin. Metronidazole remains the drug of choice for treatment of an initial recurrence even if this was the original drug used (CMAJ). Additional therapy with probiotics has been found to be effective in some patients.

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Exercise Should be Part of our Daily Routine

There is ample evidence to show that your body needs regular exercise to stay fit and healthy. Just like you need to floss and brush to keep your teeth and gums healthy. Just like you need food and water to survive. So, why is it so difficult to incorporate half-an-hour or an hour of exercise in our daily routine?

We all have our own excuses and reasons. Mostly, well intentioned people just find it difficult to set aside that kind of time to exercise. There are just too many other things to do in life like work and taking care of the family. I have been through that process myself. As I get older I find more time to go for a walk and do fairly regular exercise. Each evening I plan my next day to fit in 30 to 60 minutes of exercise time in my schedule. Most days I am able to keep my commitment.

How much exercise do we need each day?

It all depends what you are trying to achieve. Are you exercising for your heart? Are you trying to lose weight? Are you exercising to stay fit and healthy and maintain your good health? Are you exercising to find mental peace and happiness?

A study from Scotland has shown that a mere 20 minutes of physical activity a week can provide you with mental health benefit. The study also found that more physical activity in the week provided more benefits for mental health. But this is not enough for cardiovascular fitness, for losing weight and it is not enough to lessen your risks for a multitude of diseases like obesity, diabetes, cancer, depression and premature death.

The study found that 150 minutes a week (two and a half hours) of a moderate exercise such as walking and 75 minutes per week (an hour and 15 minutes) of activity like easy jogging provides good health benefits. It is also important to remember that people who are the least active to start with get the most health benefit from starting to exercise. It has been estimated that people who are physically active for approximately seven hours a week have a 40 percent lower risk of dying early than those who are active for less than 30 minutes a week.

If you are trying to lose weight then you have to remember the good old dictum: eat less and spend more calories. There is nothing like a perfect weight loss diet and there is nothing like a perfect exercise to lose weight. You have to find a program which meets with your needs. For that you have to speak to somebody who specialises in this area.

The type and amount of exercise required to be fit and healthy depends on your age, your health and your current state of physical fitness. There are three types of exercises: aerobic, weight lifting (resistance training) and stretching. A good exercise program should benefit all three aspects of fitness: stamina, flexibility and strength.

Aerobic exercise such as swimming, brisk walking, running, bicycling involves continuous activity. It increases endurance and helps body use oxygen more effectively. It makes the lungs, heart and muscles strong. It is good for cardiovascular fitness. Aerobic exercise should be combined with weight lifting and stretching. This helps improve muscle strength and flexibility. These exercises also help endurance and balance.

To retain muscle mass and strength, you should do resistance training for 20 minutes three times a week. Harvard runners study has shown that men who trained with weights for 30 minutes or more per week cut their risk of heart disease by 23 percent.

Whatever you do, make sure it is safe and you are having fun! Do it before you floss and brush your teeth – early morning, lunch hour or in the evening. Make it part of your daily routine.

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Welcome to the Wonderful World of 2010

On January 1st, as I was heading home after a couple of weeks of Christmas holidays, I was humming 1968 Louis Armstrong song, What a Wonderful World.

If you look at the news then it is hard to believe we live in a wonderful world. Deaths of our brave soldiers and recent failed attempt to blow up a plane remind us once again why we need to protect and preserve this wonderful world of ours. It is disturbing to read that even the Pope is not safe.

We have 6.6 billion people on this earth. It is hard to guess what percentage of people believes in death and destruction of human lives and property. It has to be a very small number. The vast majority of people are law abiding descent citizens of the world. My faith in human kindness is reinforced every day at work and at home. But these are the things we take for granted. We fail to appreciate the kindness because we are so busy to stop and smell the roses.

My faith in human kindness is doubly reinforced when I travel. These days travelling is not very easy. But once you embark on your journey and meet the real people like yourself you find that this world is still safe to enjoy.

I find Christmas holidays are a good time to wind up the year, bond with my family and recharge my batteries for the following year. That is exactly what I did. In the process I met some wonderful people from all over the world.

A short golfing trip to a spring like weather in Las Vegas was a good treat from the snow and cold in Canada. The flights were cheap and the hotel with golf package (including full buffet
breakfast) was a bargain. We stayed at the JW Marriott Las Vegas Resort & Spa. The resort is surrounded by most prestigious collection of golf courses.

The package includes golf at TPC Las Vegas. It is located in southern Nevada desert, surrounded by lush greens of manicured turf and surrounded by the Red Rock Canyon. The resort is about 20
minutes from the strip. The hotel has free shuttles to take you to the golf course and to the strip to gamble and enjoy the night life.

During our trip to Hoover Dam, I met a man from Washington, DC. We had a good conversation about our families. Our stories, our dreams and aspirations were very similar. There was no discussion about politics or religion. Whether it was at the resort, the golf course or at different casinos and theatres, people were nice to each other. It was all about being happy and healthy.

Once we returned to Canada, the realities of winter hit hard. So I took the advice of Hagar the Horrible in his cartoon strip where he says, “Sure we live in a frigid climate…and sure, winters are long and cold! The secret to surviving a Scandinavian winter is to stop complaining and start taking advantage of it!”

So that is what we did. We headed to the Sunshine Mountain Lodge in Banff for three days of skiing and snowboarding. My skiing skills haven’t improved much. I am still stuck to the easy green runs. But the snow, the mountains, the beautiful sunrise at 7000 ft, the beautiful new wing at the lodge and the wonderful people we met made it all worthwhile. The lodge and the Sunshine Village Ski & Snowboard Resort are staffed by young, energetic people from Canada,
the U.K., Australia and New Zealand. It was fun having a conversation with them and listening to different accents.

So here we are, back to the realities of life. But it’s a new year. Full of new possibilities, new challenges, new opportunities and new experiences. That makes life exciting. Now you know why I was humming What a Wonderful World!

Have a great year.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!