Author: noorali

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Traveler’s Diarrhea Can Cause Irritable Bowel Syndrome

Have you already planned a winter holiday? Besides getting your passport and appropriate currency, you need to think of getting your vaccinations updated and take actions to prevent traveler’s diarrhea (TD).

TD hits your system when you consume contaminated food and water. It occurs during or shortly after travel, most commonly affecting persons traveling from an area of more highly developed hygiene and sanitation to a less developed one. Food and water may be contaminated with bacteria, parasites or viruses. A similar but less common syndrome is toxic gastroenteritis, caused by ingestion of pre-formed toxins.

Studies have shown bacteria are responsible for approximately 85 per cent of TD, parasites about 10 per cent, and viruses five per cent. On average, 30-50 per cent of travelers to high-risk areas will develop TD during a one to two-week stay.

TD is generally self-limited and lasts 3-4 days even without treatment, but persistent symptoms may occur in a small percentage of travelers. Any diarrhea associated with fever and blood in the toilet requires medical attention.

Infectious diarrhea can have a long term effect on our system resulting in arthritis, Guillain-Barré syndrome (a reversible condition that affects the nerves in the body), and irritable bowel syndrome (IBS). IBS may occur in up to 30 per cent of persons who contracted travelers’ diarrhea or infectious diarrhea. Research is going on to determine if post-infectious IBS can lead to inflammatory bowel disease.

IBS is a complex disorder clinically characterized by abdominal pain and altered bowel habit. Its causative mechanisms are still incompletely known. It could be a person’s genes, psychosocial factors, changes in gastrointestinal motility and hypersensitivity of certain organs in the body.

TD can be self-limiting benign condition or may result in serious sequalae. So it is no rocket science to conclude that we should try and prevent TD by taking necessary preventive measures. Travelers should remember to wash their hands with soap and water prior to eating or meal preparation.

Eat foods that are freshly cooked and served piping hot and you should avoid water and beverages diluted with non-potable water. Foods like salads are washed in non-potable water. You should avoid that. Raw or undercooked meat and seafood and raw fruits and vegetables should be avoided. Safe beverages include those that are bottled and sealed or carbonated. Consumption of food or beverages from street vendors poses a particularly high risk.

What kind of medications can you use as prophylaxis against TD?

Studies from Mexico have shown Pepto-Bismol (taken on arrival at the destination as either two oz. of liquid or two chewable tablets four times per day) reduces the incidence of TD from 40 to 14 per cent, says one research paper. You should make sure that Pepto-Bismol is compatible with other medications you take. There is no conclusive evidence that use of probiotics is helpful.

E. coli is the most common type of bacteria which causes TD. Use of oral Dukoral vaccine (two weeks and one week before travel) provides protection against E. coli diarrhea for three months.

Use of prophylactic antibiotics has been demonstrated to be quite effective in the prevention of TD. Studies have shown that attacks of diarrhea are reduced from 40 per cent to 4 per cent by the use of antibiotics. But it is becoming difficult to decide which antibiotic to use as bacteria tend to develop resistance to antibiotics. For this and other reasons, prophylactic antibiotics should not be recommended for most travelers.

Three months before you travel, you should visit your family doctor and local public health nurse and discuss your travel plans. They will provide you with the most advanced information on how to have a healthy and happy holiday.

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Anal Fistula Can Be Difficult To Treat

This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)
This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)

Last week, I was in San Francisco, California to attend the Clinical Congress (convention) organized by the American College of Surgeons. It is one of the largest surgical conventions in the world. The convention lasts five days (Sunday to Thursday). By Wednesday afternoon, total registration for the convention was 14,397: 8916 were physicians and the rest were exhibitors, guests, spouses and convention personnel.

Not everybody is in one auditorium or room at the same time. Each room has its own list of speakers and topics for discussion. So you head yourself to a room which offers discussion on a topic which interests you the most. The conference was held at the Moscone Convention Center. It is the largest convention and exhibition complex in

San Francisco. It comprises three main halls with total of 84,000 square meters of space (900,000 square feet).

One of the symposiums I attended was on surgical problems of anus and rectum: cancer, fistula, fissure and hemorrhoids. Today, I will review the subject of anal fistula (fistula-in-ano).

What is a fistula? A fistula is an abnormal tunnel connecting two body cavities (such as the rectum and the vagina) or a body cavity to the skin (like the rectum to the outside of the body). Fistulas are usually the result of infection, injury or surgery. With an anal fistula there is a tunnel between the anus (and/or rectum) to the skin. A peri-anal abscess has a 50 per cent risk of turning into a fistula.

Anal fistulas do not generally harm the body. They are mainly a nuisance with some pain or discomfort and irritating intermittent discharge of blood, pus or stool. They can form recurrent abscesses which may require drainage under local anaesthetic.

Most of the time the diagnosis of fistula is made on the basis of classical clinical history and physical findings. Examination of the rectum may show an opening of the fistula onto the skin, the area may be painful on examination, there may be redness, a discharge may be seen or it may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula.

Treatment of the fistula depends on the presentation of the problem. If there is active infection or abscess then it needs to be treated with drainage of the pus and antibiotics. Once the infection is cleared the fistula can be treated surgically. If it is difficult to get rid of the infection then long term drainage can be established by inserting a seton – a length of suture material or thin rubber tubing is looped through the fistula which keeps it open and allows pus to drain out.

The treatment aim should be to prevent recurrence of fistula. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.

There are several options. Doing nothing – a drainage seton can be left in place long-term to prevent problems. But this does not cure the fistula. Fistula can be layed open under anaesthetic. Once the fistula has been layed open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. Depending on the depth of the fistula, this option may affect continence if the fistula involves sphincter muscles. Most fistulas are superficial and can be layed open under local anaesthetic without much problem with continence.

Other methods of treating fistula are: using fibrin glue injection, using fistula plug, creating a flap to cover the internal fistula opening and using a seton to cut through the deep fistulous tract. Each method has advantages and disadvantages.

Some fistulas are very difficult to treat if they are caused by inflammatory bowel disease like Crohn’s disease. Any patient with recurrent fistula should be investigated for inflammatory bowel disease. Otherwise, most fistulas can be cured with patience and perseverance.

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Shortage Of Doctors – A 10-Point Plan To Fix The Problem

Almost every Canadian is aware that we need more doctors. Ipsos-Reid poll done for the Canadian Medical Association indicates that MD shortages rank second only to the economy in a list of election issues (CMAJ July 1, 2008).

According to Statscan, more than four million Canadians do not have a family doctor. Currently, Canada produces 2,300 new doctors a year but we need about 3,200 doctors a year (The Medical Post, June 3, 2008). How can we find 900 more doctors each year?

According to Draft 2005 Alberta’s Physician Resources Planning Committee Report Data, Alberta, one of the richest Canadian provinces, will be short of 1,541 doctors by 2010. Dr. Dale Dauphinee, executive director of the Medical Council of Canada, coauthored a report in 1999 that calculated that Canada needs to recruit 2,500 new doctors a year. This would cover both physicians retiring or leaving the country and population growth. Our own graduates can’t fill the void.

That was in 1999, which is almost 10 years ago. Has anything changed since? Looks like things are worse now.

Over the years, so much has been said and written about finding a solution to the problem that one would think that the problem would have been solved by now.

Reports indicate there are numerous factors contributing to Canada’s shortage of physicians. Some of these factors are: migration of doctors to the United States, reluctance of medical students to choose specialties and locations where they are most needed, and new practice patterns (lifestyle goals and use of the health care system) and there are fewer doctors now partly because of a 10 per cent reduction in medical school enrolment that was imposed across the country in 1993.

What Canada has failed to do is to utilize the resources already available in our country and in overseas medical schools. We know thousands of international medical graduates are in Canada who are unable to practice because they are unable to get a license. According to CMAJ (April 10, 2007), Association of International Physicians and Surgeons of Ontario has a membership of 1800. So, how many international physicians and surgeons are in Canada who are delivering pizza or driving a taxi?

We also know there are thousands of Canadian citizens who are studying abroad because they could not wait to apply to a Canadian medical school. Generally speaking, a Canadian applicant to a medical school in Canada has roughly six per cent chance of admittance (CMAJ April 10, 2007).

There are Canadians studying in Ireland, the U.K., Europe, Australia, in several medical schools in Caribbean islands, South America, Cuba and the U.S.A. I have been to the island of Antigua twice in the last eight months and visited the American University of Antigua College of Medical School (www.auamed.org) in St. John where my son is a student. I have met and spoken to some of the people who run this place.

According to Mr. Vito Barbiera, Director of Marketing for the American University of Antigua College of Medicine (commonly known as AUA), AUA has 1200 medical students. Of these 20 per cent are Canadians, 70 per cent are Americans and the rest are from Antigua and different parts of the world.

According to the Canadian Medical Association Journal (April 10, 2007), more than 300 Canadians are now studying at four Irish medical schools, and 60 to 70 new ones join them annually. Who knows how many Canadians are all over the world striving to get a medical degree.

According to Mr. Dick Woodward, AUA’s Vice President for Enrollment Management,
AUA College of Medicine provides medical education equal to the highest U.S. medical education standards. The purpose of the training at AUA is to prepare students to pass the U.S. Medical Licensing Examination (USMLE), for U.S. medical licensure, and to provide the foundation for postgraduate specialty training in the U.S.

Woodward says, “The AUA School of Medicine is fully recognized and approved by the government of Antigua to confer the degree of Doctor of Medicine upon students who fulfill the School’s admission requirements and complete the prescribed curriculum.”

Barbiera proudly reiterates what they say on their website that AUA is the first medical school in the Caribbean with a U.S. model medical education to be hospital-integrated. AUA’s program of medical education has been approved by the State of New York and pursuant to its approval, one of the few international schools that can place its students in New York Hospitals for 2 years of clinical training.

Woodward says that AUA had a first graduating class of eight in 2007. Last year AUA produced 21 doctors and this year they expect to graduate 50 doctors. He said all AUA’s graduates have been matched in the U.S. residency programs. If these graduates are absorbed in the U.S. medical system, the question is: why cannot we engage the services of these doctors in Canada?

AUA has very ambitious plan for the future. On June 15, 2007 AUA broke ground on its new $60 million, 17-acre campus. The plan is to create an educational institution on Antigua that would provide a comprehensive state-of-the-art learning facility for students who aspire to become highly skilled compassionate physicians and plan to practice medicine throughout Canada, the United States and the Caribbean region, says AUA website.

Antigua is just one example of how U.S. is taking full advantage of recruiting and absorbing international and American physicians who pass their licensing examination by giving them opportunities of doing clinical rotations and residency program.

I propose a 10 point mini-Marshall plan to be implemented on a national level to utilize the services of international graduates in Canada who have no license to practice and Canadians studying abroad:

1. A national medical manpower czar should be appointed by the federal government. He should have sufficient budget and manpower to undertake the enormous task of making Canada self-sufficient in medical manpower.
2. The czar should create a registry of all international medical graduates who are in Canada but have no license to practice medicine. This can be done by announcements in the media.
3. The czar should conduct a survey of these graduates to find out what each one of them requires to be fully licensed to practice medicine.
4. From the responses received the czar should create conditions and provide financial help (in conjunction with teaching institutions, hospitals, licensing bodies and provincial governments) to help these graduates to be fully licensed in one year.
5. Those who fail to get a license should get one more try. If they fail again then they should be told to pursue other careers.
6. Those who accept the government help should promise to work in an underserviced area for two years before they move to another city.
7. The czar should also create a registry of Canadian medical students in all overseas countries. This can be done by announcing in the media for the parents of these students to register their children with the czar’s office.
8. The czar should take survey of these students to find out how many of them want to return to Canada to do residency program and practice here.
9. The czar should constantly stay in touch with these students and encourage them to pass LMCC (Canadian licensing examination) when they prepare for the USMLE (American licensing examination). To make it easier, the Canadian licensing bodies should accept USMLE to be equivalent to LMCC.
10. The czar should offer them financial incentives to come back to Canada by offering them signing bonuses. This can be done in conjunction with hospitals and provincial governments.

The international medical graduates and the Canadians who study abroad did not cost the Canadian tax payers a single penny. What is wrong with investing some money on them and absorb them into our system? That is better than spending thousands of dollars on Canadians who obtain their M.D. in Canada and then move to U.S. Here is a free supply of precious commodity. Canada, open your arms and take it.

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Abdominal Aortic Aneurysm Is A Ticking Time Bomb

I recently saw an ad put out by the Canadian Society of Vascular Surgeons (CSVS) calling for a national screening program for abdominal aortic aneurysm (AAA). AAA has been described as a ticking time bomb.

Now, not everybody knows where this ticking time bomb is sitting in our body. Please do not rush for a total body scan to look for this bomb and do not ask, “Doc, which wire should I pull to defuse the bomb, red or blue?” Just kidding.

Let me explain and dissect the three words: abdominal aortic aneurysm. As most of you know, abdomen is a space between the diaphragm and the pelvis. Aorta is the largest vessel in the body and runs from the heart to the pelvis. That means a segment of it passes through the abdomen. Word aneurysm is derived from Greek word aneurusma, which means to dilate. So, aneurysm is a sac like widening of an artery resulting from weakening of the artery wall.

The normal aortic width is approximately two centimeters in men and a bit smaller in women. As the aorta increases in size, the risk of rupture increases. The gradual increase in the size of the aorta occurs over several years and does not produce any symptoms. But when it ruptures and leaks the patient will develop pain in the abdomen. The clinical diagnosis is not easy but the rupture can be diagnosed with a CAT scan. Emergency surgery after a rupture does not always have a good outcome. The majority of the patients do not survive.

If AAA is detected early then elective surgery has a better outcome. Five per cent of men and under one per cent of women over the age of 65 have an AAA. It is the 10th leading cause of death in Canadian men older than age 65. Studies from the United Kingdom have shown screening programs for early detection and treatment of AAA are cost-effective and save lives.

CSVS makes the following recommendation:

-National and provincial health ministries develop a comprehensive population-based ultrasound screening program for AAA detection and referral.
-All men aged age 65-75 be screened for AAA
-Individual selective screening for those at high risk for AAA. For example: women over age 65 at high risk secondary to smoking, cerebro-vascular disease and family history of AAA and men less than 65 with positive family history.

What is required for screening? AAA can be visualized by just using simple ultrasound scan of the abdomen limited to visualization of the abdominal aorta. CSVS has reviewed data that demonstrated screening men 65 to 75 will reduce aneurysm related death by half and at seven year follow-up a benefit on all cause mortality was noted.

The data also shows three aneurysms discovered by screening and repaired electively, will prevent one aneurysm death. For men, the number needed to screen to prevent one AAA mortality is similar to mammography.

What about women? CSVS says the incidence of AAA in women is significantly less and population based screening in all women has not been shown to reduce mortality. Selective screening of women is recommended as discussed earlier.

In an interview in the Medical Post, Dr. Thomas Lindsay, a vascular surgeon and a spokesman for the CSVS says that elective surgical repair of AAA is considered when the aneurysm reaches a diameter of 5.5 cm. at which point the annual risk of rupture is in the neighborhood of 10 per cent. Persons with an enlarged aorta that hasn’t yet reached that diameter would need repeat ultrasound screenings every six months to two years.

About 1,000 Canadians suffer ruptured aortic aneurysms every year and most people die as a result. But doctors say they could cut that number in half with ultrasound screening programs.

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