Category: Medicine Hat News

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Shingles Vaccine may be Viewed as a Quality of Life Vaccine

An example of shingles. (iStockphoto/Thinkstock)
An example of shingles. (iStockphoto/Thinkstock)


A man with shingles of the face.

Shingles is caused by chickenpox virus called varicella zoster virus. The first indications that chickenpox and shingles were caused by the same virus were noticed at the beginning of the 20th century.

The incidence of shingles is mainly in adults. There are approximately four cases per 1000 population per year and a lifetime risk of 20 to 30 per cent.

Chickenpox generally occurs in children. Once the child gets over the illness the virus does not disappear from the body. Virus can settle down in one of the nerve cell bodies and lay dormant for many years.

When your resistance is low and this can be due to any reason, the virus may break out of the nerve cell and travel down the nerve causing viral infection of the skin in the area supplied by that nerve. This can happen decades after the chickenpox infection. Exactly how the virus remains latent in the body, and subsequently re-activates is not understood.

Shingles starts with burning pain, itching and tingling followed by painful rash and blisters in the area supplied by the affected nerve. The pain and rash most commonly occurs on the torso, but can appear on the face, eyes or other parts of the body. If the nerve to the eye is involved then a person may suffer loss of vision. It usually affects one nerve on one side of the body.

The rash and blisters heal within two to four weeks but some sufferers experience residual nerve pain for months or years. This condition is known as postherpetic neuralgia. About 20 per cent of patients with shingles suffer from this.

If the diagnosis of shingles is made early then it helps to start antiviral medications within 72 hours of the appearance of the rash. This reduces the severity and duration of the illness. The antiviral medications should be used for seven to ten days. The blisters crust over within seven to ten days, and usually the crusts fall off and the skin heals. But sometimes after severe blistering, scarring and discolored skin remains.

Until the rash has developed crusts, a person is extremely contagious. During the blister phase, direct contact with the rash can spread the virus to a person who has no immunity to the virus. This newly infected individual may then develop chickenpox, but will not immediately develop shingles.

Since 2008-2009, a vaccine for shingles is available for adults age 60 and over. The vaccine is used to boost the waning immunity to the virus that occurs with aging. The effectiveness of the vaccine is about 60 per cent. It is kind of a “quality of life” vaccine. It does not prevent death from shingles (an extremely rare event) but does help with postherpetic neuralgia (pain).

Booster doses of the vaccine are not recommended for healthy individuals. The efficacy of protection has not been assessed beyond four years and it is not known whether booster doses of vaccine are beneficial. This recommendation may need to be revisited as further information becomes available.

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Use of MRI in Evaluating Breast Lumps

A woman receiving a scan. (iStockphoto/Thinkstock)
A woman receiving a scan. (iStockphoto/Thinkstock)


A woman with locally advanced breast cancer.

The traditional way to assess a breast lump is to take a history, do a physical examination, do a fine needle aspiration cytology (examination of a breast lump aspirate under a microscope), mammogram and/or ultrasound, core biopsy under ultrasound control and finally, if there is no satisfactory answer then do a surgical biopsy.

A surgical biopsy gives us a definitive answer. But there are drawbacks to sending every patient with a breast lump for surgery. To start with it causes severe anxiety. You have to take a day off work. It requires local or general anaesthetic. There may or may not be postoperative complications like bleeding, bruising, discomfort, infection and pain.

On a long term basis, surgical biopsy will leave you with a scar and may be another lump which may be just a scar tissue but could be suspicious for cancer. Then you have to go through the whole process all over again.

Is there anything else we can do before going for surgery to make sure that there is no cancer in the breast?

You can ask for a second opinion. If all investigations are negative then there is a less than five per cent chance that cancer has been missed. In that case, we can leave the lump alone and provide follow up care with clinical examination and mammography or ultrasound, on a case by case basis. Sometimes a patient will ask for MRI.

MRI (magnetic resonance imaging) is a procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. MRI does not use any x-rays.
MRI is not available for routine screening. It is expensive and requires specialized equipment and personnel with good solid training to read the images. Hence, it is available in bigger cities only and is not covered by government insurance plans. MRI is more often used for breast imaging in the US than Canada because of the prevalence of private health care.

MRI is sensitive to small abnormalities in breast tissue. MRI also has limitations. For example, MRI cannot detect the presence of calcium deposits, which can be identified by mammography and may be a sign of cancer.

The value of breast MRI for breast cancer detection remains uncertain. And even at its best, MRI produces many uncertain findings. Some radiologists call these “unidentified bright objects,” or UBOs.

In women with a high inherited risk of breast cancer, screening trials of MRI breast scans have shown that MRI is more sensitive than mammography for finding breast tumors. Screening studies are ongoing.

Breast MRI is not recommended as a routine screening tool for breast cancer. However, for women at high risk, women with previous breast cancer, MRI can be useful in certain circumstances.

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Meckel’s Diverticulitis can Mimic Acute Appendicitis

A girl with lower abdominal pain. (iStockphoto/Thinkstock)
A girl with lower abdominal pain. (iStockphoto/Thinkstock)


A specimen of acutely inflamed Meckel’s diverticulum.

It was nine o’clock in the evening. I was on-call for the general surgery group. After a busy day at the office and the hospital, and after a late supper, I had just sat down to watch some news on TV. The phone rings. My wife answers. She says to me, “It’s for you, honey. It’s the hospital emergency.”

The ER physician had just examined an ill looking seven-year old boy with right sided abdominal pain, nausea, vomiting and fever. The ER doctor wanted me to come and give a surgical opinion. The question I will be asked in ER is, “Does this boy have an acute appendicitis and does he need to go to OR for surgery this evening?”

After going through the boys history and physical examination, I came to the conclusion that the kid was quite sick with abdominal signs of acute appendicitis. Possibly perforated appendicitis and peritonitis. He was dehydrated. Intravenous fluids were given, preoperative antibiotics were given and he was taken to OR.

In the OR, as soon as the kid’s belly was opened, a large amount of purulent fluid poured out. The appendix looked normal. There was a hole in the small bowel where it meets the cecum (beginning of colon) where the appendix is located. The appendix, the terminal part of the small bowel and cecum were all stuck together due to the acute inflammation. To stop the leak from the small bowel, there was no choice but remove the terminal part of the small bowel, appendix and the cecum (called right hemicolectomy).

Postoperatively the child did very well. He went home nine days after surgery. Pathology of the specimen showed normal appendix, Meckel’s diverticulum with gastric mucosa with ulceration and perforation in the adjacent small bowel and peritonitis. Acid secretion from the gastric mucosa in the diverticulum had caused the ulceration and perforation.

A Meckel’s diverticulum is a true congenital diverticulum (bulge) in the small intestine present at birth. It is a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct or yolk stalk), and is the most frequent malformation of the gastrointestinal tract.

It was first described by Fabricius Hildanus in the sixteenth century and later named after Johann Friedrich Meckel, who described the embryological origin of this type of diverticulum in 1809.

It is not that common. It is anti-mesenteric (on the free margin of the small bowel). For a medical student, the best memory aid is the rule of 2s: two per cent of the population, two feet from the ileocecal valve, two inches in length, two per cent are symptomatic, two types of common ectopic tissue (gastric and pancreatic), two years is the most common age at clinical presentation and two times more boys are affected.

Most people who are born with this have no symptoms. The most common presenting symptom is painless rectal bleeding such as black offensive stools, followed by intestinal obstruction, volvulus (torsion) and intussusception where a part of the intestine has invaginated into another section of intestine, similar to the way in which the parts of a collapsible telescope slide into one another. Over the years, I have seen examples of each one of the complication.

If a patient has symptoms and clinical diagnosis is not clear then it is worth doing a Meckel’s scan using technetium-99m (99mTc). This scan detects gastric mucosa; since approximately 50 per cent of symptomatic Meckel’s diverticula have ectopic gastric or pancreatic cells contained within them. Treatment is surgery.

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BARCELONA – A Place for Spanish Culture, Architecture and Sangria

Refreshing sangria! (iStockphoto/Thinkstock)
Refreshing sangria! (iStockphoto/Thinkstock)


La Ramblas – It is a very popular street in central Barcelona. It is lined by trees with a pedestrian mall and it stretches for 1.2 kilometers.


Catalunya Square (Placa de Catalunya). The square is a busy place. It is surrounded by shops and restaurants. This is where you pick up hop on hop off tour bus and other coaches which take you to different tourist sites.


Roof chimneys – work of Antoni Gaudi at Parc Guell.


View over Barcelona from Palau Nacional on Montjuic Hill.


Sagrada Familia (Basilica and Expiatory Church of the Holy Family). This is a large Roman Catholic church designed by Catalan architect Antoni Gaudí (1852–1926). Although it is still a work in progress since 1882, the church is a UNESCO World Heritage Site. In November, 2010 it was consecrated and proclaimed a minor basilica by Pope Benedict XVI.


Casa Batllo – the building was restored by Gaudi. It seems that the goal of the designer was to avoid straight lines completely. Much of the façade is decorated with a mosaic made of broken ceramic tiles (trencadís) that starts in shades of golden orange moving into greenish blues. The roof is arched and was likened to the back of a dragon or dinosaur.


Casa Mila (La Pedrera) roof – work of Gaudi. The undulating roof top and shard-encrusted chimneys.


Alia, Sabiya, Noorali in one of the La Ramblas street restaurants enjoying lunch with sangria

We arrived in Barcelona, Spain, for a six-day holiday. We knew there is lot to see and enjoy in this beautiful city of 1.6 million people. So we wanted to take our own time. For us, Barcelona was also a time to get over the jet lag before embarking on a Mediterranean cruise.

Barcelona is the 16th-most-visited city in the world and the fourth most visited in Europe after Paris, London, and Rome. It has mild and warm climate and numerous historical monuments. Eight monuments have been designated as UNESCO World Heritage Sites.

Our hotel was along the famous La Ramblas. It is a very popular street in central Barcelona. It is lined by trees with a pedestrian mall and it stretches for 1.2 kilometers. It is a good relaxing walk with all kinds of street entertainers, vendors and outdoor restaurants to provide you with almost everything you need.

We walked La Ramblas every day. There is ceaseless flow of pedestrians. Our hotel was at one end of La Ramblas and we walked almost a kilometer to get to Catalunya Square (Placa de Catalunya). The square is a busy place. It is surrounded by shops and restaurants. This is where you pick up hop on hop off tour bus and other coaches which take you to different tourist sites.

We took a tour of Barcelona highlights. It includes, among many other sites and monuments, Sagrada Familia (Basilica and Expiatory Church of the Holy Family). This is a large Roman Catholic church designed by Catalan architect Antoni Gaudí (1852–1926). Although it is still a work in progress since 1882, the church is a UNESCO World Heritage Site. In November, 2010 it was consecrated and proclaimed a minor basilica by Pope Benedict XVI.

It is a mind boggling and amazing structure. It is very difficult to describe it. One has to see it to understand the significance of the design and architecture. We also visited Park Guell. It is a garden complex with architectural elements situated on the hill of El Carmel in the Gràcia district. It is another of Gaudí’s masterpiece built in the years 1900 to 1914.

We went to Montjuic Hill to get a breathtaking view of Barcelona. It gave us an opportunity to visit The Palau Nacional which houses the Museu Nacional d’Art de Catalunya and site of 1992 Summer Olympics.

One day we took The Gaudi Tour. You cannot go to Barcelona and not hear Gaudi’s name in every other sentence from the tour guide. You cannot walk around the city without seeing Gaudi’s work or his influence in almost every street. Besides Sagrada Familia and Parc Guell there are couple of other famous buildings designed by Gaudi – Casa Batllo and Casa Mila (La Pedrera).

Last two buildings were close to our hotel. So we spent a day visiting both places. The architecture is out of the ordinary. Looks like Gaudi was a man who was allowed to experiment with his ideas.

On our return from the cruise we picked a hotel in The Gothic Quarter for two nights before flying back. The Gothic Quarter is the centre of the old city of Barcelona. It is a couple of minutes walk from La Ramblas. Many of the buildings date from Medieval times, some from as far back as the Roman settlement of Barcelona. There are many eating and walking areas.

A short article like this does not do justice to the history, culture and architecture of Barcelona. The food, wine and sangria will make you put on some weight. But we found walking everyday is a good way to stay fit and trim. If you plan to go then have enough time to visit many other wonderful places not mentioned here including the beaches.

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