Author: noorali

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Rabies – How Can You Prevent It?

If a dog bites me, the first thing I would think of would be rabies.

Why rabies? Because an animal infected with rabies bites, scratches or licks on a broken skin or mucous membrane of a human being, the risk of contracting rabies is high. Rabies can be transmitted through solid transplant organs as well.

Rabies is caused by a virus and is capable of infecting all mammals. An article in the Canadian Medical Association Journal (CMAJ) says that rabies is a disease entrenched in history, dating back to ancient Egypt.

In the world, rabies kills 50,000 people each year. About 20,000 people die of rabies in India and the remainder occur in Southeast Asia (particularly the Philippines), Oceania, Africa and Latin America, says the CMAJ article.

Rabies can be contracted from dogs, cats, raccoons, skunks, foxes and bats. The article says that in Canada, between 2000 and 2005, a total of 2238 cases of confirmed animal rabies were reported (about 373 per year). Skunks accounted for 40 per cent of the cases, bats for 26 per cent, foxes for 11 per cent and raccoons for eight per cent.

Since 1924, 23 Canadians have died from rabies. Since 1985, only two deaths have been reported in Canada, both from bat exposure.

It is not always easy to make a diagnosis of rabies in humans. The incubation period can be long with 20–60 days on an average. Initial symptoms can be vague. Eventually, the virus infects the lining of the brain (viral encephalitis) with classic symptoms of hydrophobia, aerophobia, hyperexcitability and autonomic dysfunction. Most patients with these symptoms die within a few days as there is no effective treatment.

Diagnostic tests require fresh samples of brain tissue. Tests are not easily or rapidly available.

Since there is no effective treatment for rabies, prevention of the disease is very important. A void contact with wild or stray animals. The CMAJ article says all stray dogs in foreign countries should be presumed to have rabies, even if the animal appears friendly. All contact with bats should be avoided, and bats should never be handled. In addition, monkeys should not be handled, and food should not be carried when visiting areas where monkeys congregate.

If you have been bitten, scratched, or licked on mucous membranes or an open wound by any animal (especially in a foreign country) then take the following actions:
-Immediately wash the wound thoroughly and vigorously with soap and water, and iodine
-Seek medical treatment immediately to receive post-exposure vaccination (five doses over 30 days for those who have not previously received pre-exposure vaccination) and human rabies immune globulin (a single dose within seven days of the first vaccine dose if not previously vaccinated).
-The incubation period for rabies is usually 20–60 days, but it may be prolonged (more than a year); therefore, it is never too late to receive treatment before symptoms develop.

Rabies vaccine is effective and substantially reduces the risk of infection when given before or after potential exposure.

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Genetic Risks – How Much Should You Know

When a physician or a nurse takes your medical history, he or she would like to know if there is a family history of any illness. You will have no clue how to answer this question if a physician, treating one of your family members, did not warn you about the illness and your risk of contracting the same illness.

An article in the Canadian Medical Association Journal (CMAJ) asks: What are the ethical and legal issues surrounding physicians’ duty to warn family members of genetic risk? This question has added importance in cases where a patient wants a physician to protect his or her privacy and not disclose the information to family members.

The article makes the point that common sense would dictate a physician to disclose such information without the patient’s consent if the physician thinks the risk is serious, imminent and preventable. But is this legally acceptable or is it just an ethical and moral obligation?

“The legal landscape around the duty to warn of genetic risk is unclear in Canada, but in some cases the benefits of disclosure may be so great as to outweigh the obligation to maintain confidentiality,” says the article.

The main reason to disclose genetic risk information is to avoid harm to other family members. The information will allow the family members to decide if they would like to undergo testing and take preventive measures. The information may help the family members make informed choices regarding marriage, career and having children who may be exposed to the same kinds of risks.

There may be some disadvantages to disclosing confidential genetic risk information without patient’s permission. The action would compromise physician-patient relationship and trust. It will violet patient’s autonomy and integrity and may cause mental and emotional distress to the patient and the family members.

In difficult situations, it would be best for the physician to explain to the patient the importance of sharing the information with the rest of the family. The article says, “Physicians fulfill their duty by informing patients of the importance of the information for family members and encouraging intrafamilial disclosure.” In my experience, in most situations, intrafamilial disclosure works the best. As a specialist, I have no information where all the family members reside. Contacting each one of them would be a huge undertaking.

Another option discussed in the article suggests that the physician should inform the patient that under certain circumstances they will disclose relevant genetic information to family members even if the patient refuses to do so.

Finally, in cases where withholding genetic risk information from other family members may cause imminent harm to the family then the physician has moral and ethical obligation to share the information with the rest of the family even if the patient refuses to do so. This may cause legal problems but preventing harm may be a good defense. It is comforting to know that a situation where there is a need for releasing confidential genetic information without the patient’s consent is pretty rare.

Do you know your family medical history and how it affects your and your children’s health?

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Statin Therapy for Your Heart

One more article on statin therapy? Yes, one more article. If you have had high cholesterol level then you know quite a bit about statin therapy. Statin therapy is extensively used for the management of high cholesterol level and in the management of coronary artery disease. One of the cholesterols is LDL (low-density lipoprotein cholesterol), also known as the “bad” cholesterol.

Recently, an article in the Canadian Medical Association Journal (CMAJ) discussed the efficacy and safety of intensive statin therapy in patients with high LDL cholesterol and coronary artery disease.

High LDL levels are associated with an increased risk for heart disease. Your doctor orders LDL testing as part of your routine check-up and it is often the first step in determining whether an individual is at risk for developing heart disease. In the management of high cholesterol level and coronary artery disease, LDL levels are often the major focus of cholesterol lowering diets and drugs.

The CMAJ article says high cholesterol level is the most important modifiable risk factor for myocardial infarction (heart attack) worldwide. High cholesterol level is directly related to high risk of dying from coronary artery disease. Studies have shown that reducing LDL cholesterol with statin therapy reduces events like heart attack by 21 per cent and death by 12 per cent.

Appropriate diet is the first line of treatment in the management of high cholesterol and high LDL. Avoid foods high in saturated fats and trans-fatty acids. Next line of treatment is cholesterol lowering medications. Commonest of these are statins. Statins reduce the bad cholesterol LDL by 30 to 50 per cent.

How low should the LDL blood level be to lower the risk of adverse events in patients with coronary artery disease? Current Canadian and American guidelines advocate LDL levels below 2.0 mmol/L in patients with coronary artery disease. Europeans guidelines differ a bit. They recommend LDL of 2.5 mmol/L in these patients.

Who should receive intensive statin therapy to lower the LDL blood level?

Analyses conducted by the authors of CMAJ article supports the use of more intensive statin regimens in patients with established coronary artery disease. What about patients who have LDL level higher than 2.0 mmol/L but have no coronary artery disease? The authors say there is insufficient evidence to advocate treating to particular LDL targets (i.e. 2.0 mmo/L) in patients without established coronary artery disease. What if these patients (the ones without coronary artery disease) have other risk factors making them prone to coronary artery disease? The authors say that there were too few clinical events in these trials to make definitive conclusions.

The authors of the article found more intensive statin therapy safe and well-tolerated. They also came to the conclusion that it helps in the prevention of heart attack and stroke in patients with known coronary artery disease, irrespective of their baseline LDL cholesterol levels. They said further research is needed to define:
-optimal LDL cholesterol targets (is 2.0 mmol/L the right target number?),
-the role of more intensive statin therapy in patients without coronary artery disease and
-the role of combination statin therapy (usually low LDL is achieved using two types of statins).

It would be a good idea to find out from your physician what your LDL level is every time you get your cholesterol level checked. If it is above 2.0 mmol/L then ask if you need statin therapy.

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Measuring Blood Pressure the Right Way

What is the accurate way to measure blood pressure?

After more than hundred years of measuring blood pressure with the use of a stethoscope and sphygmomanometer (yes, that is what your doctor uses in his office to check your blood pressure) you wonder why the question.

An article in the Canadian Medical Association Journal (CMAJ) makes the point that things have changed in the last 20 years as more and more automated blood pressure measuring devices have hit the market. Their reliability and accuracy have increased. You find them in people’s homes, in your local pharmacy and may be in your doctor’s office.

The blood pressure measurement by sphygmomanometer is called auscultatory method because the method uses a stethoscope to listen the pulse. The automated machine measures the blood pressure by oscillometric method; it detects and analyzes pulse waves to determine blood pressure.

Each method is an indirect way to measure the blood pressure. The accuracy and consistency of the measurement and its clinical relevance depends on the skill of the individual taking the pressure and proper functioning of the automated device.

High blood pressure is known to be a silent killer. The CMAJ article says that clinical practice guidelines set uniform standards to take the blood pressure so consistency and accuracy is maintained. This allows the clinician to predict the effect of abnormal blood pressure on the human body. The guidelines are based on the use of auscultation method using a bare arm – “roll up your sleeve so I can take your blood pressure.”

In another article in the CMAJ, the authors challenge the recommendation that blood pressure should be measured on a bare arm. In their study they found that taking a blood pressure reading over the sleeve of a shirt, blouse or light sweater was not statistically different than taking the blood pressure on a person’s bare arm.

The article also challenges the hypertension practice guidelines which require the use of different size blood pressure cuffs for different sized arms – some arms have a bigger circumference than others. The automated devices have cuffs which do not meet the clinical practice guidelines for measuring blood pressure by the traditional way.

The article says the use of automated blood pressure measuring devices in the clinic provides some real benefits. Well-working fully automated devices are:
-free of terminal digit bias,
-deflate at the correct rate,
-operate consistently over time,
– record the results,
-do not require good hearing and
-generally require less training to operate properly.

In spite of all these benefits, the automated device will not provide a correct reading if the patient or the individual is not mentally and physically relaxed. There are various human behaviours – emotional and physical – which affect a person’s blood pressure, albeit temporarily. So the reading taken may not be of much clinical use. Same problem applies when the blood pressure is taken by the traditional way.

So the jury is still out. The article says that in spite of advances in technology the accurate measurement of blood pressure depends on factors related to the patient, the equipment and the method used to take the blood pressure.

Have you had your blood pressure taken recently? If not, then better do so. Don’t forget, high blood pressure is a silent killer. You may not have any symptoms but your blood pressure may be high. See your doctor and roll up your sleeve or may be not.

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