Author: noorali

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What Women Should Know About HPV Vaccination?

Vaccination against human papillomavirus (HPV) infection is being promoted as beneficial to young teens before they have had sexual contact. The vaccine has demonstrated high level of antibody response especially in women who have not been exposed to the virus. Hence the target group is young girls. By preventing HPV infection, we can prevent deaths from cervical cancer.

The vaccine is almost 100 per cent effective against four types of HPV, two of which are responsible for 70 per cent of all cervical cancers. The vaccine may have cross-protection against some other HPV viruses.

Most common side-effect is pain at the injection site. Otherwise, it is a safe vaccine except recently, concern has been expressed as some cases of anaphylaxis have been reported. Usually, anaphylaxis due to any vaccination is rare, with an estimated incidence of 0.1–1 per 100,000 doses.

Anaphylaxis is a severe acute allergic reaction that is sudden in onset. The skin symptoms are the most common, followed by breathing difficulties and then trouble swallowing. The person goes into shock and by that time it may be too late to save life. Anybody who is in the business of providing vaccinations should be prepared to deal with anaphylaxis. An individual, after receiving any vaccination, should be observed at least for 15 minutes.

In the September 9 issue of Canadian Medical Association Journal (CMAJ), the subject of anaphylaxis after HPV vaccination has been discussed in detail.

A study done in Australia reported that from the 269,680 HPV vaccine doses administered in schools, seven cases of anaphylaxis were identified, which represents an incidence rate of 2.6 per 100,000 doses. They found this to be higher than comparable school-based delivery of other vaccines. The article says, “However, overall rates were very low and managed appropriately with no serious sequalae.” Identified cases of anaphylaxis following vaccination tend to occur less than one hour after vaccination.

The experts do not know why these girls had adverse reactions to the vaccine. The authors of the Australian study say that the estimated rate of anaphylaxis following quadrivalent HPV vaccine was significantly higher than identified in comparable school-based delivery of other vaccines. However, overall rates were very low and managed appropriately with no serious sequelae. None of the patients went into shock. That is good news.

According to CMAJ, in the United States, 15 cases of anaphylaxis or anaphylactoid reactions following HPV vaccination were reported to the Vaccine Adverse Events Reporting System in 2007. As of July 21, 2008, 11 cases have been reported in 2008. Over 13 million doses of this vaccine had been distributed as of the end of 2007. Although there may be underreporting, the rate of about one case per one million vaccinations is consistent with the rate of anaphylaxis following several other vaccines.

People opposed to this program would like to delay immunization until a young woman is sexually active. Unfortunately, HPV infection can occur with the first sexual intercourse, and half of Canada’s young women become sexually active by age 16.

What about the boys? Some young boys are sexually active as well. They show up with venereal warts from HPV infection. CMAJ says Canada and other industrialized countries (except for Australia) have only approved vaccination for females thus far, because studies involving males have not been completed. Hence, for now, only immunized women will be protected.

Finally, there is no doubt there is compelling evidence the HPV vaccine is remarkably safe. Preventing cervical cancer is very important. In Canada, an estimated 1300 women will be diagnosed with cervical cancer this year and 380 will die. In spite of years of Pap smears and regular screening, cervical cancer is still prevalent.

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Restless Legs Syndrome Can Affect Your Personal Health

When we are a sleep, our brain is not an idle machine. It stays very busy. It processes the information we have learned during the day. Sleep makes memories stronger. Sleep also finds hidden relations among memories and helps solve problems we were working on while awake (Scientific American Mind, August/September 2008).

There are at least 84 disorders of sleeping and waking that lead to a lowered quality of life and reduced personal health. Disturbed sleep can lead to traffic and industrial accidents. Restless legs syndrome (RLS) is one of those conditions which can disturb your sleep, can affect your personal health and can cause harm to others.

Sometime ago, there was an article in the New England Journal of Medicine (NEJM) on this subject. The article gives an example of a 45-year-old woman having had nightly insomnia for years. She reports having uncomfortable sensations in her legs when she lies down at night. She describes a feeling of needing to move her legs, which is relieved only by getting up and walking around.

This lady was diagnosed with RLS. It is also known as Ekbom’s syndrome. It is a movement disorder. It is not a psychological or emotional condition. It is thought to be a neurological disorder. Current studies are focused on a brain chemical known as dopamine.

About three to 15 per cent of the population is affected by RLS. It is more common in women than men. The prevalence increases with age. There may be a family history of the condition. Some medications can trigger RLS.

The following features should be present to make a diagnosis of RLS:
-A distressing need or urge to move the legs, usually accompanied by an uncomfortable, deep-seated sensation in the legs that is brought on by rest (sitting or lying down), relieved with moving or walking, or worse at night or in the evening.
-RLS can be associated with involuntary limb movements while patient is awake and/or periodic limb movements (PLM) while patient is asleep. Studies show that more than 80 per cent of people with RLS also have PLMs. But the majority of people with PLMs do not have RLS.

The diagnosis of RLS is based on the clinical history. RLS may be a symptom of iron deficiency therefore the iron status should be assessed. Overnight sleep study may be helpful. The article says that despite the distinctive clinical features of RLS, there remains substantial variability in responses to treatment and in clinical progression and outcome.

It seems all patients with RLS do not present with classical symptoms. Therefore, my impression is, many patients with leg pain go undiagnosed or inadequately treated.

Is there a good treatment for this condition?

For RLS, there are few medications in the market. But the NEJM article says that there is currently inadequate information on the efficacy of medications other than the group of drugs known as dopaminergic drugs.

For unexplained leg pain, rest as much as possible. Elevate the leg and take pain medications which you are familiar with. Gentle massage may improve comfort. Heat or cool soaks may help. If pain persists or swelling develops, see your family physician.

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A Dirty Wound Can Be Dangerous

During my recent family holiday, we took a day trip to a very small island of Barbuda. Barbuda is a flat coral island with an area of only 68 square miles. The island’s population of 1500 live in the village of Codrington. It is renowned for its beaches which are natural, sprinkled with pink sand, and miles long.

We were with a group of other tourists including a family doctor from England who stayed at the same hotel as we did and knew I was a surgeon. So, here we are, climbing rocks and exploring a cave. I turned around to take a picture, tripped and fell on a rock. My right leg sustained a deep nasty dirty wound with blood gushing all over the place and a piece of my precious skin and flesh lying on the bloody ground.

There was momentary panic amongst my fellow tourists when the English doctor announced with confidence, “Don’t worry, he is a surgeon!” That lightened the situation with several people offering their shirts to use as a bandage to stop the profuse bleeding.

In my mind I knew this was a serious situation. I immediately thought of two very life threatening outcomes from this episode, loss of limb or life from tetanus or flesh-eating disease. Before my trip, I had a booster dose of tetanus toxoid vaccine. But what about flesh-eating disease?

Flesh-eating disease is a form of streptococcal infection that leads to death of tissues. It is a deep-seated infection under the skin. It progressively destroys fat, fascia and muscles. The condition is also known as necrotizing fasciitis.

Streptococci (invasive group A hemolytic streptococci) may act alone or in combination with other bacteria. The infection spreads rapidly. Shock and multi-organ failure are common. Mortality is high, up to 58 percent.

Fortunately, the disease is not that common. In Canada, it is estimated that 90 to 200 cases of necrotizing fasciitis occur each year. From time to time the disease hits the headlines. Then there is long silence before another case is reported. This leaves people wondering what is this all about.

The most famous case of flesh-eating disease was Loucien Bouchard, the former premier of Quebec. He luckily survived and had to have one leg amputated.

It is not a new disease. The condition was first described in a specific body region by Fournier in 1883 and as a more generalized condition by Meleney in 1924.

Early diagnosis of this condition is not always easy. The diagnosis is clinical. Initially, it is hard to differentiate from ordinary infection of the skin. But gradually patients get very sick. The pain is more severe than the clinical findings. There are only minor changes in the skin in early phases. Unfortunately, the current state of knowledge on diagnoses and management is limited.

If the diagnosis is in doubt then surgical exploration is the best way to go. The characteristic finding is of grey, edematous fat, which strips off the underlying fascia with a sweep of the finger. Deeper changes are invariably more widespread than the skin changes.

Tetanus and flesh-eating disease are two extreme examples of how small things can get out of hand if no action is taken right away. There are many other kinds of infections which can affect dirty wounds. Even clean wounds like surgical incisions can get infected. Although the incidence of that happening is very low compared to a dirty wound.

If you sustain a dirty wound, including stepping on a dirty nail, make sure the area is thoroughly cleaned, your tetanus vaccine is up-to-date, you receive appropriate antibiotics to prevent infection and carefully monitor the progress of the wound. Before you travel abroad, make sure all your vaccines are up-to-date. Freaky things happen when you least expect it.

As for my leg, it is still there. The healing process is slow but I think I will be alright.

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Doc, My Feet Hurt

Dear Dr. B: I have been walking a lot this summer. My feet hurt and that restricts my activities. What I can do about it?

Like back pain there is no perfect cure for all ailments of the feet. Most of us are on our feet longer than any other part of our body. So our feet receive the biggest brunt of all the damage we inflict on ourselves.

Feet problems present in different ways with pain, deformity and swelling.

About 10 per cent of the general population suffer from feet pain, and in the elderly it is much higher – ranges from 53 to 95 per cent. Proximal plantar fasciitis (inflammation of the fascia – a thick tissue which runs from the heel to the ball of each foot) is the most common cause of painful feet in clinical practice, and is twice as common among women as among men.

Metatarsalgia (pain in the forefoot in the region of the base of the toes) is probably the most common cause of foot pain among middle-aged women. Most women in this age-group have been exposed to high-heeled shoes over many years.

There are many other conditions which cause painful feet. Some of these are: plantar warts, corns, calluses, ingrown toe nails, hammer toes, flat feet, bunions, arthritis, gout, stress fractures and some others.

Treatment for most of these conditions remain the same: elevate and rest your feet as much as you can – but with the busy schedule we keep, not many of us have time to do that. Other management points are: lose weight, use pain killers, hot or cold compresses, arch support, good quality fitting shoes, foam cushions to relieve pressure on painful areas, and keep feet clean and dry.

Gout and other types of arthritis may require anti-inflammatory medications. Ingrown toe nail can be surgically fixed in a doctor’s office. Some conditions require injection of cortisone to relieve inflammation and pain. Physiotherapy can relieve many ailments of the feet.

One may have to try different combinations of therapy to find relief.

Foot is a complex structure and needs to be treated with respect. There are 26 bones in our foot and they are held together by ligaments. In addition to that, there are variable numbers of accessory bones called sesamoids.

Foot is divided into forefoot, midfoot and hindfoot. When one stands normally, the body weight is equally distributed between the heel and the ball of the foot. The weight distribution depends on muscle contraction.

“Studies have shown that relatively small changes in muscle balance and tone can result in significant changes in the load distribution of the foot,” says Dr. William Hamilton in the Surgical Anatomy of the Foot and Ankle. The normal function of the foot depends on the bones, ligaments, and muscles acting in concert.

A lot depends on how you stand, how you walk, how you run, what you wear, how much you weigh, and how much care you take of your feet. Foot pain and deformities are widespread. So, treat your feet with respect. Without them you cannot go too far comfortably!

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