“Ninety percent of injuries suffered by Canadians are predictable and preventable,” says Dr Barry McLellan, chair of the National Trauma Registry Advisory Committee.

Why are they predictable and preventable?

They are predictable because we know the circumstances under which most accidents occur. They are preventable because, most of the time, the events leading to accidents can be modified.

Injuries can be intentional (suicides, homicides) or unintentional (motor vehicle accidents, falls, poisoning, fires, drowning).

With the weather getting better there are more people on the roads. They are walking, jogging, biking, or driving. Can we do something for them so they can safely enjoy what they are doing?

Yes, the following ten principles of injury prevention are developed from the information contained in the Alberta Motor Association Collision Facts and the New England Journal of Medicine:

1. Do not drink and drive. Why? Because 23 percent of drivers involved in fatal collisions had consumed alcohol prior to the crash. Males between 18 and 21 years old make up the group most likely to have been drinking prior to an accident.

2. Drive carefully on weekends and holidays. Why? The collisions fatality rate usually doubles on long weekends. In 1997, the highest number of fatal collisions happened in August, with Friday being the most collision-prone day of the week.

3. Use your seatbelt. Why? People who do not buckle up are more than twice as likely to be injured as those who wear a seat belt. The current three-point lap-shoulder restraints are thought to reduce the risk of death or serious injury by 45 percent.

4. Avoid common driving mistakes. Why? Running off the road, following too closely and left turns across the path of oncoming vehicles were the most common mistakes contributing to casualty collisions.

5. Be careful if you are young and restless. Why? Traffic collisions cause 7 out of 10 unintentional fatal injuries to people between 15 to 24 years of age. Injuries are the most common cause of death among people 1 to 34 years of age.

6. Be careful on all types of road conditions. Why? Because 60 percent of fatal collisions happen on dry roads. And 70 percent of fatal collisions occur on highways in rural areas.

7. Use children’s safety seat correctly. Why? About 50 percent of car seats are used incorrectly. Air bags can cause deaths of infants in rear-facing car seats. Car seats for children reduce the risk of death or serious injury by approximately 70 percent.

8. Use bicycle and motorcycle helmets. Why? Helmets decrease the risk of head and brain injury by 85 percent.

9. Cross streets at pedestrian crossings only. Why? Injuries to pedestrians are the second largest category of motor vehicle deaths. School aged children are at greatest risk.

10. Do not drive when tired or sleepy. Why? Because fatal car accidents increase by 7 percent in Canada on the Monday after the spring time change. When the Canadians move their clocks back an hour in the fall, collisions drop by 7 per cent. Even an hour of sleep can make a difference!

It was in 1899, U.S. reported the first death related to motor vehicle accident. Are we proud of our record in the last hundred years?

Enjoy the good weather. Be safe!

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Impotence (Erectile Dysfunction)

“My brain? It’s my second favorite organ,” says Woody Allen in Sleeper.

For many men, like Woody, a properly functioning phallus is fundamental to their self esteem, says Dr. Alain Gregoire, Consultant Psychiatrist and Senior Lecturer at University of Southampton.

The proper functioning of this organ depends on many factors – internal and external -and now chemical with the advent of Viagra (sildenafil).

Sexual function and satisfaction have many components: desire, erectile function, orgasmic function, ejaculation, and fertility. About 20 percent of men have problems relating to one of these functions.

Erectile dysfunction (impotence) is the most common complaint and the most distressing of all complaints related to sexual function and satisfaction. It can destroy a man’s ego and threaten happy relationship.

Erectile dysfunction (ED) affects 52 percent of men aged 40 to 70 years and is estimated to affect as many as 2 to 3 million couples in Canada. Many men suffer in silence and less than 10 percent of men seek medical treatment.

Now, Viagra (sildenafil) has brought the whole problem “out of the closet.”

Normal erectile function is initiated by body’s five senses: touch, sight, smell, taste, hearing and by imagination. This results in increased blood flow to the penis followed by erection.

Many medical and psychological conditions can impair erectile function. Some of them are: high blood pressure, diabetes, kidney failure, and diseases of the nervous system. Any chronic illness can have a negative effect. Several medications can do the same.

Viagra is now available in most Medicine Hat pharmacies. Before Viagra, there were limited treatment options: penile injections, suppositories, vacuum constriction devices and surgical implants. Now, there is a pill which can work within an hour.

Public’s expectations are raised to a new height!

Does it help all men with erectile dysfunction? No.

Viagra increases the blood flow to the penis. It does not increase sexual desire. It only works with stimulation. It is not an aphrodisiac. It only helps 60 to 70 percent of men with erectile dysfunction.

It has side effects too. It should not be taken by men who use nitrates (nitroglycerin for angina). If nitrate is combined with Viagra then there may be a sudden drop in blood pressure. It can also cause headaches, facial flushing, indigestion, nasal congestion, and visual problems – a bluish discoloration and difficulty differentiating blue from green.

All side effects disappear within 3 to 4 hours.

Viagra comes in 25, 50, and 100mg strengths. One pill to be taken an hour before sexual activity. Daily dosage not to exceed 100mg. Your doctor will advise you the appropriate dose for your problem.

The “little blue pill” has already helped millions of men. In U.S., 85 percent of the prescriptions were written for men between the ages of 50 and 70. The sales of Viagra are estimated to top $400 million this year in North America.

In the next few years, we will see if Viagra will stand the test of time. In the meantime, it is considered an effective and safe oral therapy for impotence.

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“Dr. B, its my indigestion. It is getting worse. Could it be an ulcer?” asks Susan as I enter the examination room.

Well Susan, what do you mean by indigestion?

“Dr. B, its my stomach!”

O.K. Susan, indigestion means different things to different people. Doctors describe indigestion as dyspepsia. Both terms are pretty vague. Medical text books describe this as a chronic (usually over 3 months), recurrent, often meal-related upper abdominal discomfort, pain or fullness.

Dyspepsia occurs in about 10 percent of the population. Most people carry on with off- the-counter medications. One-third of the people, who do seek help, will have no ulcer on investigations. This is called non-ulcer dyspepsia.

“Dr. B, what is an ulcer?” An ulcer is a break in the lining of an organ. The body responds to this with tissue reaction which may heal the ulcer or produce local tissue destruction with a crater formation.

There are 3 conditions to think about when a patient presents with indigestion: 1) ulcer of the stomach or duodenum (first part of small intestine), 2) cancer of the stomach and 3) non-ulcer dyspepsia.

Symptoms from gall bladder and pancreatic disease may mimic above conditions but they are more acute in nature with intervals where everything may be fine.

Clinically, I do not think Susan has cancer of the stomach as she is 38, has a good appetite and has not lost weight. Abdominal examination does not reveal any lumps.

Complicated ulcers can present with bleeding, weight loss, or vomiting and may mimic symptoms of cancer. Patients who are on non-steroidal anti-inflammatory drugs are prone to ulcers. In Susan’s case, there was no such history.

“Dr. B, what next? I have already tried off-the-counter medications. Is there a way to find the cause and treat it?”

Sure, Susan, let’s investigate with an ultrasound and gastroscopy. Ultrasound will check the gall bladder, liver and pancreas. Gastroscopy will examine the lining of the esophagus, stomach and duodenum.

Most of the ulcers in the stomach and duodenum are caused by Helicobacter pylori organisms (bugs). Biopsies taken during gastroscopy will identify whether these bugs are present. Gastroscopy will check for ulcer and cancer as well.

“Dr. B, you lost me! Gastroscopy? Helicobacter pylori………bugs? Scary stuff!

Susan, gastroscopy is not a difficult procedure. A flexible instrument with light and camera at the tip is swallowed under mild sedation. The magnified lining of the esophagus, stomach and duodenum are seen on a TV screen.

It allows us to do biopsies, remove polyps, dilate narrow areas, can often control bleeding and allows us to take photographs and video of the procedure.

Helicobacter pylori (H. pylori) is a bacteria found beneath the mucus layer of the stomach. In Canada, 10 to 20 percent of the population is infected with this organism. In developing countries, most people are infected before the age of 10 years.

It is estimated that 1 in 5 individuals with H. pylori will develop gastric or duodenal ulcer. A very small percentage may develop cancer of the stomach.

Susan’s ultrasound is normal. Gastroscopy reveals a duodenal ulcer with presence of H. pylori infection. Susan is treated for seven days with “triple therapy” – two antibiotics and an acid reducing agent.

Response rate to this therapy is over 90 percent for healing the ulcer and eradicating the bugs. The risk of recurrent infection is 1 to 3 percent over 5 years, usually from the immediate environment.

Susan feels great and is happy that we are able to identify the cause and treat it. A classic example of modern technology at work!

(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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Hormone Replacement Therapy (HRT)

Are you worried about menopause? Is estrogen a frightening word for you? Do you have an opinion on hormone-replacement therapy (HRT)?

Well, here is some information you may have been looking for!

Ovary secretes four types of hormones: estrogens, progestogens, androgens, and relaxin. Estrogen has the most diverse physiological effect on the body. It is mainly involved in the development and maintenance of the female sex organs. Its most general effect is to promote tissue growth.

Women, who survive to middle life, experience diminished ovarian function and reduction in hormonal levels resulting in menopause (menstrual pause!). Median age of menopause is 50 years. After menopause, the level of estrogen in blood can fall to 90 percent from their lifetime high.

With menopause come the dreaded symptoms of hot flashes, painful coitus, mild depression and osteoporosis. Osteoporosis affects about 25 percent of the elderly women and is a very serious consequence of menopause. Osteoporosis has been discussed in this column before.

Recently, NEWSWEEK reported that by the year 2000, there will be about 50 million women in America over 50. Many of them will suffer from menopausal symptoms.

Can we treat menopause? Yes, with estrogen (HRT).

For the last 41 years, the most widely prescribed HRT is Premarin – derived from the urine of pregnant mares – containing estrogens. HRT has benefited millions of women control hot flashes and other symptoms of menopause.

Are there any other benefits?

Yes. Women who are on HRT show 20 percent reduction in death rates from all causes including coronary artery disease and some cancers. Risk of having breast cancer is reduced among short term users of estrogen but is worse for women on estrogen for more than 10 years.

Estrogen has a significant positive effect on osteoporosis, delays Alzheimer’s disease, and reduces by half the chance of dying from colon cancer.

But remember the protective effect is there as long as the woman is on HRT and upto 5 years after it has been discontinued.

If HRT is so wonderful then why doctors ask: “To prescribe or not to prescribe”; and post-menopausal women ask: “To take or not to take”?

The answer is simple – the fear of acquiring breast and uterine cancer. As one of the functions of estrogen is to promote tissue growth.

But the good news is that addition of another hormone (progestin) to estrogen can substantially reduce the risk of uterine cancer.

New drugs like SERMs (selective estrogen receptor modulators) are being developed. They selectively work on bones, heart and brain but not on the breast or uterine tissues. Thus eliminating the risk of cancer in these areas.

In some cases the benefits of HRT therapy far outweigh the risks. A lot depends on your personal and family history of heart disease and breast cancer and the severity of post-menopausal symptom like hot flashes and risk of osteoporosis.

NEWSWEEK says: …….until the perfect SERM comes along, women must weigh the pros and cons of estrogen. This reminds me of what my wife always says: A woman’s work is never done….there is always something to worry about!

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