Author: noorali

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Pap Smear

How frequently should a woman have Pap smear?

The current recommendation is that all women from the age of 18 until age 69 should have a Pap smear every year. Regular Pap smear can prevent cervical cancer.

Unfortunately, 50 percent of Alberta women who develop cancer of the cervix have never had a pap smear or haven’t had smears as often as recommended, says Health Report for Albertans 2003.

This is really unfortunate. In 2002, it was estimated that 1400 Canadian women would develop cancer of the cervix and 410 would die from it, says the Health Report. Many of these lives could have been saved with yearly Pap smears.

In 1999, over 150 cases of invasive cervical cancer were recorded in Alberta, says a document produced by Alberta Cancer Board. In addition, approximately 1500 cases of cervical carcinoma in-situ (lesions that have not spread beyond the surface of the cervix) were recorded.

In the Palliser Health Region, from1996 to 2000, 19 cases of invasive cervical cancers were diagnosed (about four cases a year).

Cervical cancer used to be one of the most common and lethal cancers in women. Over the past 60 years, thanks to Pap smear, the death rate from cervical cancer has decreased dramatically.

Now some researchers are questioning the yearly screening programs.

“How often should we screen for cervical cancer?” is the title of an article in an October issue of the New England Journal of Medicine (NEJM).

The American Cancer Society (ACS) recently revised their guidelines for screening for cervical cancer because there have been reports that cost-benefit analyses of lifelong annual screening may not result in substantially better outcomes than less frequent screening and is much more costly.

ACS now recommends interval between screenings ranging from one to three years, depending on several factors, such as age, screening history, type of Pap smear, and history of patient’s immunity.

The NEJM article says that the risk of lengthening the interval for screening is that many women will forget to comply with screening recommendation.

So, it is important that every woman should remember to have a Pap smear every year unless your physician advises you otherwise.

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Irritable Bowel Syndrome

Some time ago I received a letter from one of the readers. It had multiple questions. So here are the questions and appropriate answers.

Q. Please describe irritable bowel syndrome (IBS). Is it constipation or diarrhea?

Irritable bowel syndrome is the most common chronic intestinal disorder. The symptoms are due to disturbance in the movement and sensation of the bowel. The person is otherwise well but presents with chronic or recurrent abdominal pain, change in bowel habit (constipation and/or diarrhea) and bloating.

Literature suggests at least 15 percent of the population has this condition. I feel that almost everybody has some element of irritable bowel syndrome.

It affects twice as many women as men and usually begins in early adult life. Although IBS can cause much distress, it does not lead to life-threatening illness. It is also called spastic colon.

Q. What can you do for it?

First, you have to see a doctor and get some basic investigations done to rule out any other illness like infection in the bowel, cancer, ulcerative colitis, Crohn’s disease, and celiac disease. Anemia, rectal bleeding and loss weight are not symptoms of IBS.

There is no cure for IBS. However, controlling the diet and emotional stress usually relieves the symptoms. Sometimes symptoms come and go. Some medicines may also help.

IBS is like arthritis of the gut. Just as in arthritis, your doctor may have to try more than one medication to control your symptoms.

Q. Early in spring, I had diarrhea for two weeks. Things settled down a lot since. I have a lot of gas and grumbling. Could this be due to stress?

That is quite possible. Stress plays a significant negative role in many of our illnesses. But before you blame everything on stress, you should talk to your doctor and let him decide the cause of your “back door trots”.

The subject of irritable bowel syndrome has been covered in these columns previously. These columns are available on my web site: www.nbharwani.com. Or you can pick up a copy of the relevant article from my office.

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Carpal Tunnel Syndrome

A young lady wants to know about carpal tunnel syndrome. What is it? Who gets it? How is it managed?

Carpal tunnel syndrome was first described in 1853. It is a common, painful disorder of the wrist and hand. It is caused by pressure on the median nerve in the wrist. The median nerve travels from the forearm into the hand through a “tunnel” in the wrist.

The cause of the pressure can be multifactorial. Some common causes and associated conditions are:
-repetitive and forceful grasping with the hands
-repetitive bending of the wrist
-broken or dislocated bones in the wrist which produce swelling
-arthritis, especially the rheumatoid type
-thyroid gland imbalance
-sugar diabetes
-hormonal changes associated with menopause
-pregnancy

Although any of the above may be present, most cases have no known cause.

It can occur at any age. The condition occurs most often in people 30 to 60 years old, and it is 5 times more common in women. It affects the dominant hand more frequently. It may affect both hands.

The symptoms start with pins and needles in three and half fingers (thumb, index finger, middle finger and half of ring finger) that are supplied by the sensory branch of the median nerve.

This may be followed by pain in the distribution of the median nerve, from the tip of the fingers to the neck. Symptoms may be worse at night and wake the patient from sleep. Relief is obtained by dangling the arm over the side of the bed.

Eventually, the median nerve supplying the small muscles of the hand may be affected. This produces wasting and weakness of the hand. There may be tendency to drop things.

A good history and physical examination is very important. Sometimes the condition may be confused with other problems affecting the shoulder and the neck. Therefore, nerve conduction study of the median nerve can provide more information.

The nerve conduction study helps localize the site of the entrapment and estimate the severity of damage. In less than 10 percent of the patients the test may be falsely negative. Clinical correlation is required to come to a final diagnosis.

Non-surgical treatment of carpal tunnel syndrome is: avoidance of the use of the wrist, placement of a wrist splint in a neutral position for day and night use, and anti-inflammatory medications.

Splinting can be combined with steroid injections. In one study, 80 percent had immediate relief of symptoms. But after one year only 20 percent were free of symptoms.

Ergonomic redesign of work stations is widely practiced for prevention and for relief of symptoms.

Surgical treatment involves a small incision on the palmar aspect of the wrist and the hand. The incision is deepened to divide the ligament to open the tunnel. Thus the pressure on the nerve is released.

The surgery requires no hospitalization and is done under local or regional anesthetic. No genera anesthetic is required. Studies have shown that surgical treatment relieves symptoms in 82 to 98 percent of the patients.

Relief of symptoms and return to normal level of physical activities may take few days to several months – depending on the damage to the nerve and the type of activity. Physiotherapy may become necessary.

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Trip to Jamaica! – Evidence Based Medicine

You see a doctor for a medical problem. He advises you to follow certain treatment. Do you ever ask him: Doctor, is there any scientific evidence to show that this treatment works?

Most of us trust our doctor and are too polite to ask him such a question. Instead we rely on our neighbors, friends and families to give us a second and a third opinion.

Those who are computer literate surf the internet. But you know what happens there – there are thousands of references to search for an answer.

What do doctors do when they are looking for best evidence in their practice?

Doctors go back to their text books, read medical journals, talk to their colleagues, have case conferences in hospital or attend medical meetings at exotic places.

My surgical associate, Dr. Brzezinski and I just got back from Montego Bay, Jamaica where we attended a two day conference on Evidence Based Medicine in Gastroenterology.

It was a very interesting conference. The location was beautiful – an ideal environment to learn something! The warm ocean breeze, carrying important scientific knowledge, penetrates your brain without difficulty!

There were experts from Europe, Canada and Jamaica. Main discussion was on the problems of the esophagus and stomach.

As I have said many times here, medicine is an imperfect science. Quite often the practice of medicine is an art than science. And the discussion at the Jamaican conference again confirmed that.

Only about 10 to 20 percent of what we do in medicine is evidence based. That means it is scientifically proven. The rest is based on what each one of us think is correct, what we think is best for a particular patient, it is economical and safe.

The advantage of evidence based medicine is that it helps optimize patient care and minimize variation in best practice.

The problem is that in most cases there is not enough evidence available. The clinical decision making is a very complex process because no two patients respond to a treatment in exactly the same manner.

Therefore, evidence based medicine in clinical practice is quite often not relevant.

But in spite of imperfections in medical practice, we continue to treat hundreds and thousands of patients each day. Most of them do well and respond to treatment.

Some get better just by talking to a sympathetic doctor.

Some get better by taking an aspirin and going to bed.

Some get better by doing nothing – may be a shot of brandy. Or Jamaican style – don’t worry, be happy.

Some get better by following the principles of ELMOSS – exercise, laughter, meditation, organic/healthy food, stress relief, and by giving up smoking.

But eventually, most people do get better. Time is a good healer – unless you are suffering from an incurable disease.

So, medicine is not a rocket science. But you have to know the human anatomy, physiology, pharmacology, and pathology. Then you have to put all this knowledge together and pass few exams. Then you can call yourself a doctor of medicine and surgery!

Isn’t that easy? It just takes 10 to 15 years of your life. Then you start practice and find out that only 20 percent of what you practice is based on pure science! But you can say – I have been to Jamaica!

Seriously – next time you are sick………………well see your doctor first!

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