Posts

Posted on

Tobacco Dependence Can Be Treated

“The World Health Organization estimates that, around the globe, 1.3 billion smokers purchase 10 million cigarettes every minute, and that every 8 seconds somebody dies from a tobacco-related disease,” Canadian Medical Association Journal (June 15, 2008).

Smoking is the single most preventable cause of death and disability. This has been said over and over again for many years. But smokers continue to smoke and each year we find new generation of smokers take up the habit. They get addicted and dependent on the tobacco to an extent that they find it difficult to give up the habit. In consequence they pay a price in terms of health and suffering. Not to mention the amount of money they spend to buy cigarettes and then to buy medications to treat complications of chronic smoking.

June 15 issue of the Canadian Medical Association Journal (CMAJ) has articles that review the “effective treatment for the ultimate vector of this epidemic: tobacco dependence.”

There are several effective medications available for the treatment of tobacco dependence but the problem is a failure of “dissemination of interventions from clinical trials to the broad population of tobacco users.”

Authors of one article in the CMAJ identified 69 well-designed randomized controlled trials which looked at the effectiveness of medications to help tobacco abstinence at six months and 12 months. The authors observed that varenicline (Champix), bupropion (Zyban) and 4 types of nicotine replacement therapy (nasal spray, patch, gum and tablet) roughly doubled the odds of smoking abstinence compared with placebo.

What about the nicotine inhaler?

Nicotine inhaler appeared to double the odds of abstinence as well, but the results were not statistically significant. Nicotine is also available as lozenges and nicotine sublingual tablets which dissolve under the tongue. Even in the US, 2008 guidelines on this subject agree with the above findings. The authors of the commentary in the CMAJ asks, “So why are we not doing a better job controlling the tobacco epidemic?”

The authors say that the answer is simple. It resides in our inability to disseminate effective interventions from the clinical research setting to the population. The authors give several reasons for this failure. At the physician and clinical level there is a primary emphasis on medically urgent issues, lack of time and support, inadequate training and low self-confidence among providers, and low rates of reimbursement for tobacco-treatment services.

At the population level, the authors say there is a lack of political will to restrict tobacco companies and to promote and disseminate the most effective tobacco control policies (e.g., smoke-free indoor air policies and higher tobacco taxes). Sometimes the politicians give low priority to anti-smoking programs and divert funds to other ventures.

One survey has shown that smokers in general will be receptive to receiving free nicotine replacement therapy and would use it to quit smoking. The question remains, how are we going to make the treatment accessible and affordable so we can prevent death and disability from tobacco-related illnesses? The all powerful multinational tobacco industry will not do it for us. The responsibility is in the hands of the government and the clinicians to target and encourage smokers to seek help. And the smokers should know there is help, if only they would ask.

Remember, every eight seconds somebody dies from a tobacco-related disease.

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

Posted on

What Can You Do About Varicose Veins?

Summer is here and it is time to show off your legs. But some of us are not so lucky because we have varicose veins. Nobody likes varicose veins. They are unsightly. But, do we have to hide our legs because of these veins. I hope not.

Varicose veins are enlarged veins that look dark purple or blue. They appear twisted and bulging. They are commonly found on the backs of the calves or on the inside of the leg.

Spider veins are similar to varicose veins, but they are smaller. They are closer to the surface of the skin than varicose veins. They can look like tree branches or spider webs. Spider veins can be found on the legs and face.

Deoxygenated blood from our lower limbs is transported to the heart through the veins located in the superficial and deep parts of the leg and thigh. These veins have valves which allow blood to flow one way towards the heart. Contractions of the calf muscles (also known as second pump) facilitate this process. When the valves become weak and defective there is a backflow of blood in the veins. This backflow stretch the veins and they become varicose veins.

Varicose veins and spider veins are common problems. About 40 to 50 per cent of Canadian men and women have this problem. There are many reasons why a person gets varicose veins or spider veins. The common reasons are: increasing age, genetic factors, pregnancy, hormonal changes, obesity, prolong standing and history of deep vein thrombosis (blood clot in the deep veins of the calf). Usually, there is more than one reason why a person develops varicose veins or spider veins.

Conservative measures like regular exercise (walking two miles a day), wearing support stockings and keeping legs elevated when resting and maintaining your weight does help prevent varicose veins and keep symptoms under control for those who have the problem. These veins are not life threatening. They are a nuisance and unsightly. They may give you aching legs, swelling or discoloration of the skin. They may become painful and inflamed (phlebitis).

Not all doctors treat varicose veins. Some doctors have a special interest and expertise in this area of medicine. The treatment requires patience, perseverance and some technical skills. You have a choice of conservative therapy (mentioned earlier), sclerotherapy, laser surgery or surgical ligation and stripping.

Sclerotherapy is a common treatment for both spider veins and varicose veins. The treatment involves injection of a solution into the vein that causes the vein to seal shut. You may need more than one treatment. There is about 50 to 90 per cent success rate and it is done in the doctor’s office.

Laser surgery has become very popular method of treatment. It transmits very strong bursts of light onto the vein. The vein slowly fades and disappears. The procedure involves no needles or surgical incisions. But the laser beam does produce heat sensation on the skin and can be painful. Cooling helps relieve the pain. More than one treatment is required depending on the severity of the problem.

Treatment of larger veins like the saphenous vein requires more invasive therapy. Endovenous techniques (radiofrequency and laser) require insertion of a very small tube called a catheter into the vein. Once inside, the catheter sends out radiofrequency or laser energy that shrinks and seals the vein wall. Surgical ligation and stripping of varicose veins is an old fashioned technique to fix the veins in the operating room mostly under general anaesthetic.

Choice of treatment depends on the severity of the problem. Each procedure has advantages and likely complications. Discuss your problem with your family doctor and get a referral to a physician who is skilled in the management of this problem. Don’t forget to work on your second pump.

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

Posted on

What’s New About Osteoporosis?

Osteoporosis is a condition in which there is a gradual softening of the bones which makes them fragile. It is caused by the loss of calcium. Our current understanding has been that osteoporosis occurs most often in women after the age of menopause. Men can suffer from osteoporosis as well when they experience low levels of testosterone.

Bone fracture is a common complication of osteoporosis. One in two women and one in five men over the age of 50 will have a fracture. A person may lose height if the vertebra collapses due to osteoporosis. One may develop a hump if several vertebrae collapse.

Other causes of osteoporosis for men and women are: long-term use of corticosteroid medication, maternal osteoporosis, smoking, heavy drinking, sedentary lifestyle, low body weight and medical conditions that affect absorption, such as celiac disease. Diagnosis of osteoporosis is made by measuring bone mineral density.

A recent article in the CMAJ says that our understanding of and approach to osteoporosis is in the middle of a revolution. Research now shows the bone loss begins before menopause and involves other hormones in addition to estrogen, and that measuring bone mineral density alone is an inefficient way of addressing the clinical burden of osteoporosis.

The ongoing Canadian Multicentre Osteoporosis Study also shows that both men and women experienced an additional phase of accelerated bone loss from age 70 onward. Hormone replacement therapy with estrogen in women does protect against bone loss over time.

The finding that bone loss began before menopause indicates that estrogen loss alone cannot account for the changes. Therefore, interest has focused on other hormones whose levels change in early menopause such as follicle-stimulating hormone and the activins and inhibins. The role of steroid produced in the body and the size of the body composition is being determined.

The current national guidelines recommend that the test for osteoporosis (measuring bone mineral density) should be done every 2-3 years. In one of the CMAJ articles, Berger and colleagues suggest that densitometry for most women can be repeated every five years rather than every 2–3 years because the average changes in bone density over 2–3 years is small and comparable to the measurement error in the scanning technique.

There is also a question whether women who are already receiving treatment for osteoporosis should have follow-up assessments of bone density at all, since changes in density as a result of therapy account for only a small component of the effectiveness of these medications, says the CMAJ article.

There are four key points in the CMAJ articles: bone loss in women begins before menopause and is accelerated in old age, medications which reduce the loss of calcium from the bone helps preserve bone density, the interval between bone density assessments can safely be increased to 5 years for many untreated women and finally, decisions about when to test and treat will increasingly focus on estimates of absolute fracture risk as indicated by the bone density test.

Osteoporosis is treated with calcium and vitamin D supplements, a variety of hormone treatments (hormone replacement therapy like estrogen) and Bisphosphonates, a group of drugs that prevent bone breakdown and can be very effective in osteoporosis. But prevention is better than cure. So, increase calcium and vitamin D in your diet, increase the amount of weight-bearing exercise you do, reduce your alcohol intake and quit smoking.

So, have you had your glass of milk today?

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

Posted on

Warning – Mosquitoes Are Here To Hurt Us

My first article on West Nile virus was in 2003. Not much has changed in the last five years. Mosquitoes continue to threaten us every summer. Summer is a time to be free, be outdoors and have fun. But mosquitoes spoil the fun.

Every year we go through this process of reminding ourselves to protect against this horrible virus. Just like we do in winter against flu virus. The difference is there is no vaccine yet against West Nile virus.

This year the battle has already started. Alberta Government has been advertising in the media to remind us about the precautions we need to take to prevent mosquito bites. Dr. Paul Schnee, Medical Officer of Health and Gordon Wright, Health Promotion Facilitator, both from Palliser Health Region, have been relentless in reminding the doctors and the public about West Nile virus.

I thought mosquitoes would consider me their friend and spare me from their horrible stinging bites. You see, I was born and raised on the shores of Lake Victoria. A small town called Musoma, in Tanzania, East Africa. There was no shortage of mosquitoes and malaria in Tanzania. Then I moved to India to go to college. There is no shortage of mosquitoes there either. Now in Canada, I am faced with the same battle. I have been fighting mosquitoes all my life. They show no respect for me. And they show no respect to public in general.

West Nile virus was first isolated in 1937 from the blood of a patient on the West Nile province of Uganda. Not too far from where I was born. The man had fever. Initially, the outbreaks of the disease were few. But in the last 15 years the numbers have increased.

In North America, the virus was first detected in 1999. It was in New York. From there it was exported to Ontario and rest of Canada. Most cases of West Nile virus are mild and self-resolving. But one per cent of cases get infection in the nervous system.

West Nile virus is carried by birds. Mosquitoes get infected by feeding on the blood of these birds. Infected mosquitoes then transmit the virus to humans when they bite us.

All mosquitoes need water to develop from their immature stages to adulthood. The life cycle takes less than 10 days to complete if the surrounding temperature is favorable. Once the adult mosquito is ready to fly then it looks for something to eat.

Nectar from flowers provides energy to both male and female mosquitoes. While male mosquitoes feed exclusively on nectar, the female mosquito needs blood to produce her eggs. The source of blood can be animals (including people) and birds.

It is important to control the breeding sites around your home by preventing stagnation of water (flower pots, gardening cans, wheelbarrows, puddles, tire swings, bird baths and eavestroughs) even in small quantities. Boats and gardening containers can be stored upside down. These are just a few examples.

During mosquito season you should limit your outdoor activities. Minimize exposure of your skin by wearing long pants, long sleeves, socks and shoes when outdoors. Loose clothings will keep mosquitoes away from the skin. Use insect repellents like DEET. Read the directions carefully before using DEET-based repellents especially in children, infants and yourself.

Remember, Culex tarsalis is the mosquito that spreads the virus here. The Culex is just out and is now active. It comes to us from July to September (first freeze). Now is the time to start really watching for this one, says Gordon Wright, Palliser’s Health Promotion Facilitator. There is no sign of the virus yet, but we are assuming it will be here soon, says Wright.

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