Category: Medicine Hat News

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Ebola Virus Disease has a High Fatality Rate

Robin building nest. (Dr. Noorali Bharwani)
Robin building nest. (Dr. Noorali Bharwani)

Ebola virus disease (EVD), as it is known now, was formerly known as Ebola haemorrhagic fever. It is a severe, often fatal illness in humans. It is a disease of the wild animals and then it is transmitted to people. It spreads in the human population through human-to-human transmission.

The Ebola virus causes an acute, serious illness, which is often fatal if untreated, says WHO website. Ebola virus disease first appeared in 1976 in two simultaneous outbreaks, one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name.

Previously the disease was confined to small villages near tropical rainforests. The most recent outbreak in West Africa has involved major urban as well as rural areas. The case fatality rates have varied from 25 to 90 per cent in past outbreaks.

Controlling the disease has been difficult. According to the WHO website, community engagement is key to successfully controlling outbreaks. Good outbreak control relies on applying a package of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe burials and social mobilization.

Currently there is no licensed treatment for the disease. Treatment is base on providing rehydration with fluids and treat any other symptoms that the patient presents with. A range of blood, immunological and drug therapies are under development.

The current outbreak started in March 2014 in West Africa. WHO calls this the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 1976. There have been more cases and deaths in this outbreak than all others combined. It has also spread between countries starting in Guinea then spreading across land borders to Sierra Leone and Liberia, by air (one traveller only) to Nigeria, and by land (one traveller) to Senegal. Latest report has confirmed a case in the US. By the time you read this the numbers may change.

How does a person get infected with Ebola virus?

It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts. Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest.

How does it spread among humans?

Ebola then spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.

WHO says people remain infectious as long as their blood and body fluids, including semen and breast milk, contain the virus. Men who have recovered from the disease can still transmit the virus through their semen for up to seven weeks after recovery from illness.

First symptoms are the sudden onset of fever fatigue, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding (e.g. oozing from the gums, blood in the stools). Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.

Confirming the diagnosis and providing treatment continues to be a challenge. There is lot more information available on the WHO website.

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Medications That Put Our Seniors in the Hospital

Summer Flowers (Dr. Noorali Bharwani)
Summer Flowers (Dr. Noorali Bharwani)

I covered this topic about three years ago. It is never too early or too late to review the subject again.

A study published in the New England Journal of Medicine says 40 percent of people over 65 take five to nine medications every day. What this means is that hospitalizations for accidental overdoses and adverse side effects are likely to increase among this group.

The study found that every year, about 100,000 people in the United States over age 65 are taken to hospitals for adverse reactions to medications. Most of the patients are there because of accidental overdoses. Sometimes the amount of medication prescribed for them had a more powerful effect than intended.

The four most common groups of medications putting seniors in hospitals are: warfarin (a blood thinner), insulin injections for diabetes, antiplatelet drugs to thin the blood and oral diabetes drugs.

Warfarin accounts for the most visits due to adverse drug reaction. It accounted for 33 percent of emergency hospital visits. Warfarin (Coumadin) is an anticoagulant – popularly referred to as a “blood thinner.” In reality, it does not make the viscosity of the blood thin. What it does is that it acts on the liver to decrease the quantity of a few key proteins in blood that allow blood to clot.

It was initially marketed as a pesticide against rats and mice. Later it was found to be effective and relatively safe for preventing blood clots in humans. It was approved for use as a medication in the early 1950s and now it is the most widely prescribed oral “blood thinner” drug in North America.

Insulin injections were next on the list, accounting for 14 percent of emergency visits. Insulin is a hormone central to regulating carbohydrate and fat metabolism in the body.

Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle. When control of insulin levels fails, diabetes mellitus will result. Patients with type 1 diabetes depend on insulin injections.

Antiplatelet drugs like aspirin, clopidogrel (Plavix) and others that help prevent blood clotting were involved in 13 percent of emergency visits. An antiplatelet drug is a member of a class of pharmaceuticals that decrease platelet aggregations and inhibit clot formation. They are effective in the arterial circulation, where “blood thinners” have little effect.

Lastly, diabetes drugs taken by mouth, called oral hypoglycemic agents, which were implicated in 11 percent of hospitalizations. Anti-diabetic medications treat diabetes mellitus by lowering glucose levels in the blood. There are different classes of anti-diabetic drugs, and their selection depends on the nature of the diabetes, age and situation of the person, as well as other factors.

The authors of the article say that in order to reduce the number of emergency hospitalizations in older adults we should focus on improving the safety of this small group of blood thinners and diabetes medications, rather than by trying to stop the use of drugs typically thought of as risky for this group. And patients should work with their physicians and pharmacies to make sure they get appropriate testing and are taking the appropriate doses.

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Unused Prescription Drugs Should be Disposed of Carefully

A lonely tree. (Dr. Noorali Bharwani)
A lonely tree. (Dr. Noorali Bharwani)

It is a common dilemma in every household – what to do with expired and unused medications.

An article in the Canadian Medical Association Journal (CMAJ August 5, 2014) says unused prescription drugs should not be treated like leftovers and kept sitting in a closet for years to come.

On May 11, 2013, Public Safety Canada and the Canadian Association of Chiefs of Police coordinated the first National Prescription Drug Drop-Off Day, which resulted in the return of more than two tones of unused medications, says the CMAJ article. This initiative was repeated on May 10, 2014.

The whole idea of this exercise was to reduce the amount of unused prescription drugs in Canadian households and, ultimately, drug-related harm. Unused prescription drugs are common in most households.

Some individuals are reluctant to throwaway unused medications because they may be useful in the future. A good example is painkillers. A second example is antibiotics.

A review found that more than a third of patients did not complete their antibiotic course as prescribed, and unused antibiotics were taken by more than a quarter of the patients for new infections.

If you keep unused prescription drugs in the house then another member of the family may think that the same pills may be useful for his or her ailment.

Unused opioids, benzodiazepines and stimulants are major sources of misuse and diversion, says the article. Fifteen per cent of students in grades seven to 12 in Ontario reported using prescription medications (most often opioids and stimulants) for recreation in the preceding year. Most of these pills were prescribed to one of the parents or sibling.

Unused prescription drugs are sometimes brought to “pill parties” (also called “pharm” or “Skittles” parties), where adolescents experiment with pills they select from the pool of medications brought by partygoers, says the article. Some of the drugs can kill if mixed with other drugs or alcohol.

Self-medication with antibiotics, without proper professional diagnosis, is a common practice, most often for a sore throat and common cold.

What about our toddlers?

Between 2001 and 2008, more than 450 000 cases of poisoning in children less than six years of age were reported to US poison control centers. Of these, 95 per cent involved the ingestion of a prescription medication, which resulted in substantial morbidity and resource use (i.e., non-fatal injury, visit to the emergency department and admission to hospital), as well as 66 deaths, says the article.

To minimize these kinds of harm, there should be responsible disposal of unneeded or expired medications.

Health Canada recommends that unused medications be returned to local pharmacies or municipal waste disposal centers and should not be disposed off in the garbage or by flushing them down the toilet.

Flushing the pills down the toilet is not a bad idea although Health Canada does not like it. The US Food and Drug Administration recommends disposal in the garbage after the unused medications have been mixed with coffee grinds or cat litter to mask the drug or render it unpalatable. Not an easy disposable system.

The most important thing to remember is all medications should be stored in a secure place.

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What is New About Carpal Tunnel Syndrome?

Sunset in the prairies. (Dr. Noorali Bharwani)
Sunset in the prairies. (Dr. Noorali Bharwani)

August seems to be my favourite month. Many good things and some not so good have happened during this month. One of the good things was starting this column 16 years ago. A by-product of these columns has been publication of my two books. Hopefully, there will be more.

OK, let us get back to what we are going to discuss today – carpal tunnel syndrome.

Last time I wrote about carpal tunnel syndrome was in 2003. This is a good time to review the subject again as I saw an article in the Canadian Medical Association Journal (CMAJ August 5, 2014).

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 CMAJ article says the condition is not as common as thought. “A prospective long-term study of a general working-age population (16 to 74 yr) showed that the overall incidence of carpal tunnel syndrome over a 66-month period was 103 per 100 000 people per year,” says the article.

Who is at risk?

Individuals who are working in areas where there is exposure to excess vibration, use of increased hand force and repetitious movements increase the risk of carpal tunnel syndrome. In an analysis of 37 studies it was found that factors significantly associated with increased risk included vibration, increased hand force and repetition.

What about somebody spending many hours using computer keyboard?

The authors of the article say that the association between carpal tunnel syndrome and use of a computer keyboard or mouse is unclear. The authors reviewed eight epidemiologic studies and came to the conclusion that the evidence is insufficient to confirm that computer work causes carpal tunnel syndrome.

The review also found no evidence of an association with repetitive, low-force noncomputer work.

Personal characteristics that increase a patient’s risk include increase in age, sex (women were at higher risk than men) and obesity.

Is there a good treatment for carpal tunnel syndrome?

After 160 years, one would think we would have found a good treatment for this ailment. Let us see what we have.

Initial management may include occupational therapy and wrist splinting. A study found that eight weeks of splinting and education sessions with an occupational therapist was helpful in 63 per cent of the patients. These patients did not require surgery.

These patients showed improvement in symptom severity, functional status, pain perception and grip strength. The article says if symptoms do not improve within eight weeks, referral to a surgical specialist should be considered.

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