Author: noorali

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New year is a good time to control the silent killer.

Sunrise at Haleakala Volcano summit in Maui, Hawaii. (Dr. Noorali Bharwani)
Sunrise at Haleakala Volcano summit in Maui, Hawaii. (Dr. Noorali Bharwani)

In the new year, you can wish for many things and make many resolutions. But don’t forget to take care of the silent killer – your blood pressure.

The lifetime risk for developing hypertension (high blood pressure) among adults aged 55 to 65 years is 90 per cent. Our New Year’s resolution should be to keep our blood pressure under control.

More about that later. First, I have a question for you: when is the best time to take your blood pressure pill?

Currently, there are no guidelines on when to take your blood pressure pills – is it better to take it in the morning or at bedtime?

The answer is in an article recently published in the British Medical Journal (BMJ 23 October 2019) titled “Taking antihypertensives at bedtime nearly halves cardiovascular deaths when compared with morning dosing.”

A study of nearly 20,000 hypertensive patients in primary care has shown taking pills for high blood pressure at bedtime is associated with improved blood pressure controls. Besides, the risk of dying from cardiovascular causes is reduced by half when compared with morning dosing.

The Hygia Chronotherapy Trial randomly assigned 19,084 hypertensive patients (median age 60.5 years) to take their entire daily dose of one or more antihypertensives at bedtime or on waking in the morning. The patients were followed up with ambulatory blood pressure monitoring, for a median follow-up period of 6.3 years.

The results show these patients have better controlled blood pressure and, most importantly, a significantly decreased risk of death or illness from heart and blood vessel problems.

The researchers found there was enough evidence from this study to recommend patients consider taking their blood pressure medication at bedtime.

It should be noted that this recommendation does not apply to medicines that need to be taken more than once a day or to blood pressure medicines that are prescribed for other problems, such as angina or heart failure.

Do not change your medication schedule without consult your doctor.

What is considered to be high blood pressure?

Blood pressure that is consistently more than 140/90 mmHg is considered high, but if you have diabetes or chronic kidney disease, 130/80 mmHg is high, says Health Canada website.

High blood pressure significantly increases risk for stroke, ischemic heart disease, peripheral vascular disease and heart failure.

Some facts about high blood pressure (hypertension):

  1. Hypertension affects more than one in five people.
  2. Approximately 17 per cent of individuals with hypertension are not aware of their condition, the true prevalence of hypertension is likely higher.
  3. Hypertension is the most common reason to visit a doctor.
  4. Hypertension is the number one reason for taking medication.
  5. The lifetime risk for developing hypertension among adults aged 55 to 65 years with normal blood pressure is 90 per cent.
  6. It is estimated that almost 30 per cent of hypertension can be attributed to excess dietary sodium. Reduction in daily sodium intake to recommended levels could result in one million fewer Canadians with hypertension.
  7. Smoking, being overweight or obese, lack of physical activity, too much salt, stress, genetics and family history can induce hypertension.

That is it for this year. Let me wish you all Merry Christmas, Season’s Greetings, Happy Healthy Safe and Sober New Year! Remember what Earl Wilson (American Athlete) said, “One way to get high blood pressure is to go mountain climbing over molehills.” Talk to you next year.

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

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New guidelines on investigating thyroid dysfunction.

Equipment for all seasons. (Dr. Noorali Bharwani)
Equipment for all seasons. (Dr. Noorali Bharwani)

The thyroid gland produces hormone called thyroxine. The gland is in the front of the neck, below Adam’s apple, consisting of two lobes (left and right) connected by an isthmus.

In fact, the thyroid gland secretes three hormones: the two thyroid hormones, thyroxine (T4) and triiodothyronine (T3); and calcitonin.

The thyroid hormones influence the metabolic rate and protein synthesis, and in children, growth and development. Calcitonin is involved in helping to regulate levels of calcium and phosphate in the blood.

Many things can go wrong with the thyroid gland. Examples of thyroid disorders include hyperthyroidism (increased activity), hypothyroidism (reduced activity), thyroid inflammation (thyroiditis), thyroid enlargement (goitre), thyroid nodules, and thyroid cancer.

In iodine-sufficient regions, the most common cause of hypothyroidism is the autoimmune disorder Hashimoto’s thyroiditis.

Most adults who go for regular annual physical examination get tested for thyroid function. Is this necessary?

The Canadian Task Force on Preventive Health Care (CMAJ November 18, 2019) strongly recommends against screening for thyroid dysfunction in asymptomatic nonpregnant adults. Why? Guidelines say, “Treating asymptomatic adults for screen-detected hypothyroidism may result in little to no difference in clinical outcomes.”

These recommendations do not apply to patients with previously diagnosed thyroid disease or thyroid surgery; exposure to medications known to affect thyroid function; exposure to thyroid radioiodine therapy, or radiotherapy to the head or neck area; or pituitary or hypothalamic diseases.

Guidelines suggest clinicians should remain alert to signs and symptoms suggestive of thyroid dysfunction and investigate accordingly. This is not always easy. The signs and symptoms of thyroid dysfunction are variable between patients and often nonspecific.

Symptoms of hypothyroidism may include tiredness, sensitivity to cold, dry skin, hair loss, weight gain and slowed movements and thoughts. If left untreated, hypothyroidism may increase the risk of cardiac dysfunction, hypertension, dyslipidemia, cognitive impairment and, in rare cases, myxedema coma.

If the thyroid is overactive (hyperthyroidism), symptoms may include regular rapid heartbeat (sinus tachycardia), atrial fibrillation, hyperactivity or irritability, intolerance to heat, tremor and weight loss.

Some people with thyroid dysfunction have no symptoms.

Thyroid dysfunction is diagnosed based on abnormal levels of serum thyroid-stimulating hormone (TSH) and can be characterized as either hypo- or hyperthyroidism.

Minor variations in thyroid function as measured by abnormal levels of TSH are often self-limiting. Observational studies have reported that levels of TSH appear to revert to normal without treatment in 37 to 62 per cent of patients with initially elevated levels and 51 per cent with initially low levels, particularly for milder cases of thyroid dysfunction (mean follow-up 32–60 months).

Summary of recommendation for clinicians, policy-makers and patients

The guidelines recommend against screening asymptomatic nonpregnant adults aged 18 years and older for thyroid dysfunction in primary care settings.

Screening results in overuse of resources without a demonstrated benefit.

These recommendations do not apply to patients with previously diagnosed thyroid disease or thyroid surgery; exposure to medications known to affect thyroid function (e.g., lithium, amiodarone); exposure to thyroid radioiodine therapy, or radiotherapy to the head or neck area; or pituitary or hypothalamic diseases.

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

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Is cannabis good for mental health?

Aswan, Egypt. (Dr. Noorali Bharwani)
Aswan, Egypt. (Dr. Noorali Bharwani)

Cannabis has been smoked for psychoactive effects at least for 2,500 years.

Each day more than 400 Canadians are hospitalized because of harm from alcohol or drugs.

Every day 10 Canadians die in hospitals from harm caused by substance use. Cannabis accounts for nearly 40 per cent of hospital stays among youth for harm from substance use.

Incidence is high among youth age 10 to 24. Statistics show the heaviest users of cannabis consume a high proportion of alcohol as well.

Nearly 70 per cent of the hospitalizations for harm caused by substance use involve mental health conditions.

What is cannabis?

Cannabis, also known as marijuana among other names, is a psychoactive drug. Psychoactive drug changes brain function and perception, mood, consciousness, cognition, or behavior.

Cannabis can be used by smoking, vaporizing, within food, or as an extract.

Onset of effects is felt within minutes when smoked, and about 30 to 60 minutes when cooked and eaten. The effects last for two to six hours. Short-term side effects may include a decrease in short-term memory, dry mouth, impaired motor skills, red eyes, and feelings of paranoia or anxiety.

Long-term side effects may include addiction, decreased mental ability in those who started regular use as teenagers, and behavioral problems in children whose mothers used cannabis during pregnancy.

There is a strong relation between cannabis use and the risk of psychosis.

Is cannabis good for mental health?

A review of 40 years’ worth of studies suggests cannabis may not be effective in treating mental health disorders, but experts say that might have more to do with the lack of high-quality research than the drug itself.

A review article published in Lancet Psychiatry (Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis. October 28, 2019), looked at 83 studies dating back to 1980 on cannabis as a treatment for depression, anxiety, attention-deficit hyperactivity disorder, Tourette syndrome, post-traumatic stress disorder and psychosis.

The study concluded there was “scarce evidence” to suggest cannabis improves the symptoms of any of these conditions based on 3,513 participants.

Not all experts agree with this study. Some felt the data from the studies examined in the review isn’t necessarily up-to-date. Some felt the data was of low quality. There was no discussion in terms of what people are actually consuming. Certainly, more research is needed on the medical benefits of cannabis in the treatment of mental health problems. For example, randomized controlled trials related to cannabis and psychiatric conditions would help to come to scientific conclusion.

Experts believe cannabis should not be the first line of treatment for psychiatric disorders as there are many unanswered questions. For example: How often should a person take it, dosage, and how long should they take it for? There is a risk that cannabis can make certain psychiatric conditions like schizophrenia worse.

It is not prudent for a physician to recommend cannabis for mental health disorders without first trying well tried therapies and other proven medications. Use of cannabis in mental health is an uncharted territory. For medical purposes, cannabis isn’t a proven treatment for mental health disorders.

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

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The pleasures and perils of winter.

Marigot (French side), Saint Martin and the Caribbean Sea. (Dr. Noorali Bharwani)
Marigot (French side), Saint Martin and the Caribbean Sea. (Dr. Noorali Bharwani)

Winter is here! Some people have died. Some have exacerbation and/or complication of their pre-existing conditions. Some have broken bones. Some have flu. Some are depressed.

The lucky ones – if that is an appropriate word for them – are in Hawaii or Florida. Some are in Arizona or Palm Springs. Some are on a cruise in Bahamas or South America. Some are on the big mountains, gyrating down the slopes on their ultra super speed skis.

The big chill does create a new dynamics in peoples’ lives. As soon as the leaves start gathering on the ground, we are gripped with fear or joy depending on what we have planned for the snowy days.

But we carry on. Sometimes smiling, sometimes annoyed and sometimes angry. Each morning, we get ready for work in our best winter clothes. At work, the heating is on and the windows are shut. Your comfort level goes down. Your smile fades and your layers start coming off. You look out of the window for some inspiration and comfort. You see a pile of snow. You feel trapped.

Do you find this stressful? Does this affect your health?

About 50 per cent of deaths in winter are related to coronary artery disease and blood clots in the brain.

Studies have shown that most deaths occur 24 hours after cold days. This appears to be due to brief rather than prolonged exposure to cold. Resulting in rapid changes in the blood viscosity, formation of blood clot and increase demand for oxygen by heart muscles.

Those who are already known to have coronary artery disease are prone to spasm of these vessels. This further aggravates the risk of heart attacks. Asthmatics run the risk of aggravating their condition by inhaling cold air especially during exercise.

The precise mechanism of cold-induced changes is being hotly debated by the experts. Engorgement of blood vessels and release of substances which produce spasm of lung vessels are responsible for asthmatic attacks.

Patients with Raynaud’s disease suffer significant spasm of blood vessels of hands and feet when exposed to cold. This occurs mainly in young healthy women. Their blood vessels are extremely sensitive to cold or emotions.

In most of these conditions, the underlying mechanism appears to be the effect of cold on blood vessels.

Asthmatics, who want to enjoy winter sports, should keep inhalers (bronchodilators) handy at all times. People with heart problems should wear a light face mask to maintain a favorable air temperature and humidity during exertion. Warm clothings, mittens, gloves and socks should protect the rest of the body from the big chill.

Remember, better safe than sorry! We still have almost four months of winter to enjoy. Keep smiling!

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