Miscellaneous Health Topics

Some items of interest from the world of medicine:

1. Infant Homicide:

Infanticide (killing of a child in the first year of life) is the subject of a special article in a recent issue of The New England Journal of Medicine. The timing of the deaths, potential risk factors and prevention are discussed.

In Europe, in the early 1800s, up to a third of live-born infants were killed or abandoned by their parents. In the U.S., between 1983 and 1991, 2776 cases of infanticides are identified by the authors. The problem has not disappeared.

Studies have shown that homicide during the first week of life is usually committed by the mother. After that age, the culprit is usually a male, often the father or stepfather of the victim. In children three years and older, the perpetrator is usually unrelated to the victim.

On Friday, Nov 20th, The Medicine Hat News reported that three people in Salt Lake City are accused of murdering a three year old child-one of the accused being the child’s mother from Alberta.

So, what are the risk factors? Usually, the mother is young, has been pregnant before, has low level of education and gets late prenatal care. The infant has low birth weight, usually is a male who arrives earlier than due date.

How can we prevent infanticide? The authors of the special article feel that “…the identification of risk factors and interventions must take place during pregnancy, at the time of delivery, and in the immediate postpartum period.”

Studies have shown that child abuse can be reduced by home visits from trained nurses during pregnancy and in the first two years of life of a first-born child of an unmarried mother with low socio-economic status.

2. Do Rich People Live Longer?:

A U.S. study, on the above subject, is discussed in an editorial in one of the recent issues of the Annals of the Royal College of Physicians and Surgeons of Canada.

The study confirms the long held belief that the rich do live longer than the poor. But, this has nothing to do with the life style of the affluent. In fact, in U.S., the authors of the study found that the major factor for high death rate amongst the poor is due to inadequate access to timely and high quality health care.

3. What women don’t know could kill them:

This is the title of an article in a recent issue of The Canadian Medical Association Journal.

Most of us know that heart and blood vessel diseases are number one killer. Women make up 40 percent of these deaths. But, a recent Heart and Stroke Foundation survey shows that only 17 percent of the Canadian women are aware of this.

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Pancreatic Cancer

“Doc, few days ago, my neighbor’s wife, Yazmin, died of pancreatic cancer at the age of 59. Her husband, Yusuf, is devastated. He feels guilty. He thinks he could have done more to save her.”

Dave looks upset. I know when something is bothering him because normally he would say: What’s up doc? Busy today?

“Dave, here is some information which may help.”

Pancreatic cancer is the fifth leading cause of cancer death in North America. In 1992, 214 Albertans died of the disease (males 114, females 100). In 1993, 216 new cases were diagnosed in this province (males 98, females 118).

The prognosis is dismal. The overall 5 year survival rate is less than 2 percent, the worst of any cancer. Only 20 percent of the patients will be diagnosed at stage where surgery may offer hope.

The surgery is extensive with significant complications. Even those who survive the ordeal, the 5 year prognosis may not be better than 25 percent.

“Doc, why is it difficult to make an early diagnoses?”

Two main reasons: first, the pancreas is a long, narrow, transverse, deep seated organ behind the stomach in the upper abdomen; second, the initial symptoms are none or very vague. By the time ultrasound or CAT scan picks it up, it is too late.

Dave is surprised to hear that. He tells me about the difficulties Yusuf and Yazmin have overcome over the past 25 years. They had arrived penniless as refugees from Uganda with six children: the youngest, triplets, were about a year old.

Yusuf is a good watch repairer. After moving from few unsatisfactory jobs, he opened his own business: a jewelry shop. Yazmin did the “salesmanship” and Yusuf repaired watches. They were happy.

As parents, they had their share of problems raising children. Their oldest daughter has multiple sclerosis. Now, Yusuf has to deal with the tragedy of losing his wife.

Dave was almost in tears. “Doc, what causes pancreatic cancer?”

The precise cause is unknown. Smoking and chronic inflammation are suspected in the causation of the disease. An estimated 5-10 percent of pancreatic cancers are inherited and additional 10-20 percent may have other significant genetic influence (Current Oncology-July 1998).

“Doc, thanks for listening. I will go and see Yusuf. See if I can help him with the information I have.”

Good luck, Dave.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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Miscellaneous Health Topics

Some items of interest from the world of medicine:

1. Screening: what does it mean?

Physicians’ opinions differ on the meaning of the word “screening”. One definition used in the Canadian Medical Association Journal (Oct, 20 1998) is: “Screening for disease control can be defined as the examination of asymptomatic people in order to classify them likely, or unlikely, to have the disease that is the object of screening.”

Screening is recommended for variety of diseases-malignant and non-malignant. This is based on the premise that benefit will follow if an asymptomatic person undergoes a particular test.

2. Violence against health care workers:

There is a growing trend toward violence in society at large, says Barbara Sibbald, in an article in the Canadian Medical Association Journal (Oct, 20 1998). She is an Associate Editor of the Journal.

Statistics Canada data indicate that the number of violent crimes committed annually per 100 000 Canadians increased from 865 to 1037 between 1988 and 1994.

The figures from BC Workers’ Compensation claims resulting from workplace violence indicates that BC nurses now face the same risk of workplace violence as police officers – nearly 4 times the incidence of any other profession.

Health care workers in psychiatry and emergency medicine are more exposed to violence in a hospital setting. Danger can follow physicians outside the institutions they work in. Some of the reasons given are: cutbacks in the health system, political differences and/or ideological motivation.

3.Death from recreational activities:

Drowning is the leading cause of death related to recreational activities in Canada and is exceeded only by motor vehicle crashes and drug overdose as the cause of death among young adult men, says the Canadian Medical Association Journal (Aug, 11 1998).

Nearly 40 percent of all drowning result from boating accidents, and most of these involve motorized boats used for fishing and power-boating. High use of alcohol and low use of personal flotation device is the 2 main reasons for the boating related deaths.

4. A pill for every ill?

A recent Statistics Canada survey found that 10 percent of seniors had taken 5 or more drugs during the 2 days immediately before they were surveyed (Canadian Medical Association Journal, Aug, 11 1998).

That numbers rose to 13 percent among respondents aged seventy five or older. A full 10 percent higher than for the population as a whole.

The 1994-95 National Population Health Survey found that pain relievers, high blood pressure and heart pills, water pills (diuretics), stomach remedies and laxatives were the most common prescription and nonprescription medications taken by seniors.

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Rectal Bleeding and Hemorrhoids

“Hello doctor, I am Maggie, Susan’s mother. I have been passing blood in my stool. Do you think it is hemorrhoids? Dave and Susan think it could be cancer.”

Maggie is sixty seven. She has been bleeding rectally for the last two years. Over-the-counter medications for local application have not helped. Has she got colon or rectal (colorectal) cancer?

Colorectal cancer affects men and women equally. It is the fourth most common cancer site. It is the second leading cause of cancer deaths in men and women combined ( A Snapshot of Cancer in Alberta-1996).

Do we know what causes colorectal cancer? No. If we did then prevention and cure would be easy. But we do know the risk factors.

Like breast cancer, age is a significant factor. Before the age of forty, the incidence is pretty low. But by the age of fifty, the risk begins to increase dramatically.

What about lifestyle and nutrition?

Studies have shown that death from colorectal cancer can decrease with increased intake of fiber, fruits, and vegetables. Decrease in fat intake also helps.

Increased physical activity, aspirin and avoiding cigarette smoking may be beneficial.

Heredity and genetics is now recognized as a risk factor for this disease. Studies have shown that if there is a family history of colorectal cancer in a parent or a sibling , then a person’s lifetime risk of colorectal cancer jumps from 1.8 fold to 8.0 fold.

Previous history of colorectal cancer or polyps, inflammatory bowel disease and exposure to radiation are other significant risk factors.

With this information in the back of my mind, I take a full history from Maggie and do a thorough physical examination.

The physical examination is normal. A digital rectal examination reveals no suspicious lumps. A proctosigmoidoscopy ( a hollow tube with a light at one end to examine the rectum) shows internal hemorrhoids but no lumps to suggest a new growth of tissue.

Although Maggie has internal hemorrhoids, there are about fifty percent chances that the blood could be coming from higher up in the colon. This may or may not be due to cancer. But she requires further investigation like colonoscopy.

Examination of the entire colon by colonoscopy (a thin, flexible tube made of fibers that transmit light) is the most important test for looking, taking biopsies and when possible, removing growths. Maggie agrees to have the test done as soon as possible.

Maggie has to take laxatives to clean the colon completely of waste products the day before the procedure. The test is done at the hospital as day surgery and under sedation.

A polyp (new growth of tissue) is discovered and removed during colonoscopy. This is sent to the lab for testing to see if it is benign or malignant. In the meantime, she makes an appointment to see me in the office for the results.

Susan accompanies Maggie to make sure her Mom understands the results and its implications. Susan also wants to know how the findings will affect her (Susan’s) health in the future.

“Maggie, I have good news for you. The polyp is benign in nature but it’s a type which can come back and turn into cancer if not picked up early and removed.”

“Dr. B, thank you for the good news. Now I have the same old question for you. How can my mom and I stay one step ahead of the game?” Susan asks with a sense of relief.

Eat less fat. Eat more fiber-containing foods. Have a digital rectal examination and annual stool test for hidden blood and colonoscopy every 3 to 5 years. Report to your doctor earlier if there is any change in bowel habit.

Maggie and Susan are happy that this is all over. As they leave the examination room, I overheard Maggie say to Susan, “I hope now you will listen to your mother and start eating bran flakes cereal in the morning!”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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

Miscellaneous Health Topics

Some items of interest from the world of medicine:

1. Heart Disease:

Heart disease continues to be number one killer. This was recognized in the late 1940s. Since then several risk factors have been identified, including high blood pressure, high cholesterol level and cigarette smoking.

Over the past 30 years, death rate from heart disease has declined by more than 50 percent. This downward trend is continuing. Despite important advances in treatment and prevention, heart disease remains the single most common cause of death in North America.
(The New England Journal of Medicine, September 24, 1998)

2. Alcohol Problems in Canada:

In 1994, 4.1 percent of Canadians had alcohol dependence. Excessive alcohol abuse was a factor in 6701 deaths in this country in 1992. Clearly, alcohol abuse is an important public health issue that needs to be dealt with.

In a recent publication, Poulin and colleagues found that 85 percent of Canadians with alcohol dependence do not seek help, the need for screening and brief interventions is great.
(Canadian Medical Association Journal, Dec 1, 1997)

3. Teenage Girls and Smoking:

Weight control is a major reason that teenage girls take up smoking, according to a study of nearly 3000 British and Canadian school girls.

Girls who smoked were 30 percent more likely to be overweight, were prone to overeat, and were twice as likely to be worried about their body image than non-smokers.

Most smokers also wanted to be considerably thinner than they were and were twice as likely as others to induce vomiting after overeating.
(British Medical Journal, August 8, 1998)

4. Doctors and Religion:

The Medical Post 1997 National Survey of Doctors reveals that 52 percent of physicians consider religion an important part of their life. 26 percent pray outside formal religious services at least once a day. For 13 percent, religious beliefs influence birth control consultations.
(National Survey: the Medical Post 1997 National Survey of Doctors, Fall 1997)

5. Good Health and Multivitamins:

Since the mid-1970s, twenty five percent of American adults have regularly consumed a multivitamin containing 400 micrograms of folic acid. The current evidence suggests that people who take such supplements and their children are healthier.

Consuming a standard multivitamin or a serving of fully fortified breakfast cereal is a convenient, effective, safe, and inexpensive way to increase consumption of folic acid by 400 micrograms of folic acid rapidly.

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Prostate Cancer

“Is it my prostate, doc?” Dave asks me at the golf course as he rushes to the washroom for the fifth time.

As a travelling salesman, Dave finds it difficult to make many washrooms stops. He makes an appointment to see me.

Dave is 40. His father has had prostate cancer. Dave wants to know what are his risks and what can he do for prevention and early detection.

The prostate is a small gland, usually weighing about 20 grams. It surrounds the urethra where it joins the bladder. Enlargement of the gland causes voiding problems and may cause bleeding in the urine which may or may not be visible.

Prostate cancer is, after lung cancer, the most common cause of cancer-related death in men. The risk of developing prostate cancer increases with age. At 40, the probability of prostate cancer occurring within five years is 0.01 per cent. At 80, it is eight per cent.

Although the risk is only eight percent, it is important to note that 80 per cent of men at 80 will have prostate cancer. But this will not affect life or life expectancy.

“What’s up doc?” Dave greets me as I enter the examination room.

We discuss symptoms. In a physical examination we find his prostate is slightly enlarged, smooth but quite firm.

There are no hard lumps to cause alarm at this stage.

Although most prostate cancers are diagnosed at 70, they can occur at a younger age. Since Dave has a family history and his prostate is enlarged and firm, he is referred to Urologist for further investigation.

Dave has a blood test – prostate-specific antigen (PSA). This is slightly abnormal. Therefore he has rectal ultrasound and a needle biopsy. This is reported as normal.

“Doc, how often should I have checkups for my prostate?” Dave asks.

His Urologist indicates Dave should have a repeat antigen test in three to six months.

If this is abnormal then he may need a repeat prostate biopsy.

Screening is recommended for men 50 and over. Half the men in this age group develop prostate problems. This may or may not be due to cancer.

Digital rectal examination and antigen tests are recommended for screening high risk patients like Dave. Although neither tests are hundred percent accurate for early diagnoses, they are accepted as part of routine medical checkups.

Dave is happy there is no cancer and his anxiety level improves. He feels reassured about his health.

He is ready to hit the road for another few days of good salesmanship.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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

Breast Lump

Dave and Susan were anxiously waiting for me.

Since her last visit, Susan has practiced breast self examination. She found a breast lump.

Susan is aware that breast cancer is the most common cancer diagnosed in Alberta women. It also accounts for about 21% of all cancer deaths in women (Breast Cancer – The Picture in Alberta: 1998).

Susan came straight to the point. She told me about her breast lump.

“Dr B, do you think it is cancer?”

“Susan, I will have to do some investigations before I can answer your question.”

I started with clinical history. How long the lump has been present? Has any change been noted? Is there a previous history of breast biopsy or breast cancer?

Age is the most significant risk factor for breast cancer in women. At age thirty, the probability of developing breast cancer in the next five years is 1 in 667. At seventy, it is 1 in 65.

Susan is thirty eight. Her risk is 1 in 208.

Any other risk factors? Susan’s sister had breast cancer. It is estimated that less than 10 percent of all breast cancers have genetic predisposition.

Breast cancer may or may not be painless.

A fine needle aspiration biopsy of the lump was required to establish whether the lump is solid or cystic. A cystic lump has a very low probability of cancer. I also arranged a mammogram. This would provide further information on the nature of the lump. It would also pick up smaller lumps which were not felt during the physical examination.

Susan and Dave were made aware that eighty percent of breast lumps are benign in nature but a breast lump is suspected to be malignant unless proved otherwise.

Within a week I had good news for Susan. The needle biopsy and mammogram did not reveal cancer. She was advised to see me seven to ten days after she starts her next menstrual cycle.

Susan arrived as planned.

I gave her another physical examination to see if the lump had changed or even disappeared. The lump was still there.

Unfortunately, none of the tests we do are hundred percent accurate to rule out cancer.

“Doctor, I know this. I have been talking to my sister. What’s next for me? A surgical biopsy?”

Yes. This would entail a surgical procedure under local or general anesthetic.

Susan underwent day surgery as planned. There was no cancer.

I saw Susan again a few weeks later. She was happy and relieved.

“Doctor, what should I do to stay one step ahead of the game?”

Mammography and physical examination are the mainstay of screening in breast cancer (Cancer Screening in 1995; Current Oncology; March 1995).

Susan got ready to leave. I gave her some pamphlets to read.

“Call me if you have any questions,” I said as Susan stepped out of the door.

She smiled and said, “Thank you, doctor!”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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