Are you Prepared to Stay Safe and Healthy in Winter?

Dinosaurs at the Royal Tyrrell Museum in Drumheller, Alberta. (Dr. Noorali Bharwani)
Dinosaurs at the Royal Tyrrell Museum in Drumheller, Alberta. (Dr. Noorali Bharwani)

Winter is here and it is just the beginning of cold weather. This is the time to plan for the next six months. Here are some reminders for you, for your health and your safety.

First, we have to prepare ourselves for our own safety with winter jackets and shoes. Second, we should make sure our home and vehicles are ready for winter. You should prepare for power outage and outdoor activity. We should not forget to check on our older neighbours and relatives.

Install good quality windows. Insulate water lines which are close to exterior walls. Check your heating systems. Have your heating system serviced. Fireplaces and chimney should be checked.

Smoke detector batteries should be tested and replaced twice a year.

Carbon monoxide detectors. If you don’t have one then get one. Change the battery when you change your clocks. Carbon monoxide is colourless and odourless. Symptoms of poisoning are headache, dizziness, weakness, upset stomach, vomiting, chest pain, and confusion.

Prepare your vehicle for winter. Get it serviced before winter sets in. Keep the gas tank full to avoid ice in the tank and fuel lines.

It is a good idea to carry emergency winter kit in your car. Especially, if you do a lot of out-of-town driving for work or pleasure. Prepare a winter emergency kit to keep in your car.

If you are stuck in your vehicle and are waiting for help then run the motor (and heater) for about 10 minutes per hour. From time to time open one window slightly to let in air. Make sure that snow is not blocking the exhaust pipe – this will reduce the risk of carbon monoxide (CO) poisoning.

Don’t forget to check on your neighbours. Make sure your pets stay inside.

To be safe is important. It is also important to enjoy the winter outdoors. There are many healthy winter sports which are popular in Canada. Especially, in Alberta we are blessed with beautiful mountains and snow.

One can enjoy ice skating, skiing, sledding, snowboarding, snowmobiling, hockey, curling, ice fishing and more. If you don’t like to be out in the snow then you can join a gym and do some indoor workout.

Most common causes of injury in winter sports are falls and collisions. You can substantially reduce the risks with common sense and proper planning, preparation and equipment.

Studies have shown that the participants in the cold-weather games are going through events at faster speeds and spend more time in the air than those competing in warm-weather sports. Risk of injury increases.

Enjoy the winter safely. Make sure you have the right clothings, equipment and training. Be involved in group activity so help is there in case of injury. Have fun!

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Thyroid Malfunction Can Result in Serious Consequences

Exophthalmos. (Dr. Noorali Bharwani)
Exophthalmos. (Dr. Noorali Bharwani)

It is estimated 200 million people in the world have some form of thyroid condition. One in every three Canadians has a thyroid disorder. Of those, as many as 50 per cent are undiagnosed. Most thyroid disorders are five to seven times more common in women.

Thyroid hormones are produced in the thyroid gland from iodine and an amino acid, tyrosine. The normal function of the thyroid gland is to produce and secrete hormones. There are two hormones which are closely related: T3 (triiodothyronine) and T4 (thyroxine).

These hormones have enormous impact on our health, affecting all aspects of our metabolism. They maintain the rate at which our body uses fats and carbohydrates, help control our body temperature, influence our heart rate, and help regulate the production of protein. These hormones are important for normal growth and development of children.

Problems with the thyroid can be caused by iodine deficiency and autoimmune diseases, in which the immune system attacks the thyroid, leading either to hyperthyroidism (Graves’ disease) or hypothyroidism (Hashimoto’s disease).

Graves’ disease – overactive thyroid

This condition was first described by Caleb Parry in 1786, but the pathogenesis of thyroid disease was not discovered until later. Parry was an Anglo-Welsh physician credited with one of the earliest descriptions of the exophthalmic (bulging eyeballs) goiter, published in 1825.

Now the condition is known as Graves’ disease. It is named after Robert J. Graves, an Irish physician who described it in 1835. Graves’ disease is an autoimmune disease characterized by hyperthyroidism (over active thyroid gland). We don’t know why this happens.

Graves’ disease is the most common cause of hyperthyroidism. The condition accounts for at least 90 per cent of all patients with hyperthyroidism. It is an autoimmune condition. The immune system normally produces antibodies to protect us and are designed to target a specific virus, bacteria or other foreign substance. Here, it is attacking our own system. An enemy within us!

Clinically, hyperthyroidism presents with palpitations, nervousness, tremor, heat intolerance, weight loss, muscular weakness and quite often there is goiter.

In Graves’ eye disease, the eyes are painful, red and watery – particularly in sunshine or wind. The eye lids and tissues around the eyes are swollen with fluid. The eyeballs bulge out of their sockets (exophthalmos). Because of eye muscle swelling, the eyes are unable to move normally and there may be blurred or double vision. Some patients have decreased colour vision as well.

With treatment, in most patients, the eyes tend to get somewhat better when the thyroid abnormality has been treated.

Hashimoto’s disease – underactive thyroid

There is another autoimmune thyroid condition called Hashimoto’s thyroiditis. It is named after Japanese physician Hakaru Hashimoto (1881−1934), who first described the symptoms in 1912. It affects more women than men.

This condition is characterized by the destruction of thyroid cells by various cell- and antibody-mediated immune processes. This condition is the most common cause of hypothyroidism. The treatment of choice for Hashimoto thyroiditis is thyroid hormone replacement.

Hypothyroidism causes many symptoms: weight gain, lethargy, cold intolerance, menstrual irregularities, depression, constipation, and dry skin. Deficiency of thyroid hormones in children leads to dwarfism and mental retardation.

Treatment of hypothyroidism with synthetic thyroid hormone is usually simple, safe and effective. Finding an adequate replacement dosage of thyroid may take a little time.

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Are we making any progress in the management of pancreatic cancer?

"We can learn a lot from trees: they're always grounded but never stop reaching heavenward." -Everett Mamor
"We can learn a lot from trees: they're always grounded but never stop reaching heavenward." -Everett Mamor

Some years ago, my sister died of pancreatic cancer. She was only 60-years old. Not long ago, a friend of mine died of the same illness. Over the years, as a general surgeon, I have looked after many patients with pancreatic cancer. None of them lived more than six to 12 months after diagnosis.

Most common pancreatic cancer is pancreatic adenocarcinoma and this represents more than 90 per cent of diagnoses.

Long-term prognosis for pancreatic cancer depends on the size and type of the tumor, lymph node involvement and degree of metastasis at the time of diagnosis. The earlier pancreatic cancer is diagnosed and treated, the better the prognosis. Is this possible?

Unfortunately, pancreatic cancer usually shows little or no symptoms until it has advanced and spread. Therefore, most cases (up to 80 percent) are diagnosed at later, more difficult-to-treat stages.

Compared with many other cancers, the combined five-year survival rate for pancreatic cancer – the percentage of all patients who are living five years after diagnosis – is very low at just five to 10 per cent. This is because far more people are diagnosed as stage IV when the disease has metastasized.

With this information in my mind, I was curious to read an article on this subject in the Canadian Medical Association Journal (Advances in the management of pancreatic ductal adenocarcinoma, CMAJ June 7, 2021).

The article says the incidence of pancreatic carcer is rising and is projected to become the third leading cause of cancer death in Canada. The reason for this is not known. Observational studies have shown that smoking, obesity and a prolonged history of diabetes, are associated with a higher risk of developing pancreatic cancer. A family history of pancreatic cancer in a first degree relative is reported in about 10 per cent of patients.

Surgical resection remains the only opportunity to cure pancreatic cancer, and only about 20 per cent of patients present with resectable disease.

The CMAJ article has five recommendations for the management of pancreatic cancer:

  1. Germline testing is now recommended for all patients with pancreatic cancer. Pancreatic cancer is associated with numerous hereditary syndromes and the results of germline testing can help guide treatment selection.
  2. In suitable patients, modified FOLFIRINOX is the adjuvant chemotherapy regimen of choice, after surgical resection.
  3. Neoadjuvant approaches for resectable disease are increasingly common and should be considered in patients with high-risk features such as an elevated carbohydrate antigen 19.9 level at diagnosis.
  4. Patients with borderline resectable or locally advanced pancreatic cancer should have induction combination chemotherapy, when possible, before consideration of surgical resection or a local therapy.
  5. If resources allow, patients with advanced pancreatic cancer should have molecular profiling of their tumours to detect uncommon but therapeutically targetable somatic alterations.

These five treatment options are not easy to understand for people who are not involved in the management of pancreatic cancer. And cure for pancreatic cancer is nowhere in sight. Cure is only possible if the cancer is diagnosed early. Only up to 10 per cent of patients who receive an early diagnosis become disease-free after treatment. For rest of the pancreatic cancer patients the prognosis is poor.

If the tumour is resectable and there are no metastases then the person can live for 2.5 years after their diagnosis and have a five-year survival rate of 20 to 30 percent.

For early detection of cancer, we put many individuals through screening tests like pap smears, mammograms, colonoscopies etc. Should we put individuals age 60-years and older to go through ultrasound, computerized tomography (CT) scans, magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) to pick up early pancreatic cancer? Can the health care system afford the cost of it? How many people will benefit? How many lives will be saved? Something for us to think about.

Be safe. Take care.

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Antihistamines Should Be Used Properly

Pacific Ocean. (Dr. Noorali Bharwani)
Pacific Ocean. (Dr. Noorali Bharwani)

Antihistamines are used to treat hay fever and other allergies. They work by preventing the effects of histamine, which is produced by the body. Histamine can cause itching, sneezing, runny nose, and watery eyes.

Allergic reaction occurs when our body’s immune system mistakes a harmless substance for a harmful one, and the body releases chemicals to fight it. This reaction is what causes the symptoms.

Hay fever is an allergic reaction to substances in the air like pollen. This can be indoors or outdoors. Besides pollen, one can have allergy to dust mites, or tiny flecks of skin and saliva shed by cats, dogs, and other animals with fur or feathers.

Allergic rhinitis refers to inflammation of the nasal passages due to the release of histamine and other mediators in the nose. Allergy testing helps with the diagnosis. Allergic rhinitis may be seasonal (usually due to grass, tree or weed pollens) or perennial (due to triggers such as pet hair, house dust mite or mould). Allergic rhinitis can lead to increased asthma symptoms.

Allergic conjunctivitis is another condition similar to allergic rhinitis. It can be seasonal due to pollens or perennial due to allergens present all year.

An article titled “How to use antihistamines,” was published in the Canadian Medical Association Journal (CMAJ April 6, 2021) which says, “Antihistamines are among the most commonly and incorrectly used medicines worldwide.”

The article says antihistamine use is most strongly supported for treating allergic rhino-conjunctivitis (hay fever) and urticaria (hives). It says we should not use antihistamines for conditions where antihistamines have questionable utility, such as in managing asthma, eczema, or cough.

Older (first generation) antihistamines are associated with substantial and sometimes fatal adverse effects. They cause sedation, injury and impairment in sleep. They interfere with mental and cognitive function, including impaired performance at school.

Older antihistamines should be avoided in the elderly. Overdose can result in death. Examples of older antihistamines are: Benadryl, Chlor-Tripolon, and Atarax.

The CMAJ article says, “Newer antihistamines are safer, as affordable and as efficacious as first-generation antihistamines.”

Compared with first-generation antihistamines, systematic reviews of randomized controlled trials have found newer antihistamines to be safer, longer lasting (12–24 hours) and faster acting. Their effect is felt in 50 minutes compared to 80 minutes for the first-generation antihistamines.

Warning – no antihistamine should be consumed with alcohol. And antihistamines should not be used for anaphylaxis. For this purpose, epinephrine is the drug of choice.

What you should know about second generation antihistamines.

Second generation antihistamines are newer medicines. Many treat allergy symptoms without causing sleepiness. The CMAJ article gives a summary of preferred antihistamines for allergy and urticaria: Bilastine, Cetirizine (Reactine), Desloratadine (Aerius), Fexofenadine (Allegra), Loratadine (Claritin), Rupatadine (Rupall).

It is important to remember some antihistamines are mixed with other medicines. These could include pain relievers or decongestants. These are meant to treat many symptoms at the same time. It is a good idea to treat just the symptoms that you have. If you have only a runny nose, don’t choose a medicine that also treats headache and fever.

There are other uses of antihistamines. For example: to prevent motion sickness, nausea, vomiting, and dizziness. In addition, since antihistamines may cause drowsiness as a side effect, some of them may be used to help people go to sleep, relieve anxiety, and produce sleep before surgery.

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