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Thyroid lumps need investigations to rule out cancer.

Sunset in Saint Martin, Caribbean. (Dr. Noorali Bharwani)
Sunset in Saint Martin, Caribbean. (Dr. Noorali Bharwani)

Thyroid is a small gland located at the base of the neck, just above the breastbone. Thyroid nodules are solid or fluid-filled lumps that form within the thyroid gland. Most of them are benign. Thyroid cancer accounts for only a small percentage of thyroid nodules.

Small thyroid lumps are not visible to the naked eye. Some nodules are big enough to be seen. Sometimes your doctor will feel the lump when he examines your neck.

A solitary nodule, within an otherwise apparently normal gland, is of more concern than a thyroid gland with multiple nodules (multi-nodular goiter). Multi-nodular goiters are usually benign.

Thyroid nodules are more common in women. Single nodule is four times more common in women than men.

About 45 to 75 per cent of nodules are simple cysts (colloid nodules); 15 to 40 percent are benign tumours (adenomas); and only eight to 20 per cent are cancerous.

A patient with a history of radiation treatment to the neck, or any radiation exposure near the thyroid gland, has increased risk of developing nodules. These nodules tend to develop long after the radiation exposure. Family history of thyroid cancer increases the likelihood of a thyroid nodule being malignant.

How do we investigate a solitary thyroid nodule?

The most recent guideline from the American Thyroid Association recommends measurement of thyroid stimulating hormone (TSH) level in the blood and ultrasound of the neck in all patients with a thyroid nodule, says an article in the Canadian Medical Association Journal (CMAJ December 6, 2016).

Ultrasound is a good test for thyroid lumps. It can tell us if there is more than one nodule, if the lump is solid, cystic or mixed; and it is the best method to determine the size of the nodule.

Blood test is also useful. A low TSH level (< 0.3 mU/L) suggests an autonomously functioning nodule, and a thyroid scan with iodine-123 should be performed.

Although nodules are present in 20 to 70 per cent of individuals, most do not require biopsy.

If the nodule is hyper-functioning then it requires medical treatment. Surgery is rarely indicated.

If the TSH level is normal or high (> 5 mU/L), then fine-needle aspiration (FNA) biopsy should be considered. All thyroid nodules do not need a needle biopsy. Only non-cystic nodules greater than one to two cm need to be biopsied. FNA biopsy is recommended for nodules with features on ultrasound that indicate higher risk of malignant disease.

If the needle biopsy is negative for cancer in the first instance then the new guidelines recommend a repeat needle biopsy after three months. Repeat needle biopsy yields a more definitive diagnosis in up to 90 per cent of cases based on high-quality studies, says the CMAJ article.

After two benign needle biopsy results, ultrasound surveillance is no longer indicated. However, if the lump gets bigger or causes symptoms then there is an indication for surgical treatment.

So, a solitary thyroid nodule is not always malignant. But it should not be ignored. Appropriate investigations should be done to rule out cancer.

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Simple Steps for Keeping Your New Year’s Resolutions

Happy New Year 2017 (Dr. Noorali Bharwani)
Happy New Year 2017 (Dr. Noorali Bharwani)

The year is almost over. If you are one of those individuals who believes in making one or more New Year’s resolutions then the time has come.

About 50 per cent of the adults will start off 2017 with at least one promise to change for the better.

Statistics show six in 10 people drink alcohol regularly but only three in 10 get involved in regular exercise. Men are more physically active than women. Sixty per cent of the adults are overweight (BMI 25 to 30) or obese (BMI over 30). Forty per cent of the adults do not have adequate sleep. So there is lot to change.

I believe one should keep New Year’s resolutions simple. Eating healthy, doing physical exercise regularly, not smoking, avoiding alcohol or only drink in moderation, maintaining a healthy body weight, and sleep at least eight hours each night would be a good start.

You need only one resolution, “In 2017, I want to be healthy and stay healthy. I will apply the KISS (keep it simple stupid) principle.”

If you do not have self-discipline to accomplish your goals then there are many organizations and individuals who can help. YMCA is a good place to start.

Do not forget to spend time with your loved ones. No goals are complete without the love and affection of your partner and family. In fact get the family involved in your pursuit of good health and make it more fun. Keeping those you love close and making time for your family can be an important goal.

You should be able to find 15 minutes in a day to meditate. May be during lunch hour or in the evenings before going to bed. There are many physical and mental benefits to meditation. You will find this will provide significant reduction in your stress level.

Listening to music and/or reading a book in a quite place can be very peaceful and healthy. I find spending few hours in the library very relaxing and I am able to stay focused in what I am trying to achieve.

Most people find losing weight very difficult. Again the principal is simple. Eat less and exercise more. Try to lose 10 pounds in a year (not in a week or a month) and then you will find you can lose 30 pounds in three years. It can be that simple. Slow and steady wins the race. And apply the KISS principle.

A new study released a few days ago (British Medical Journal, Dec 13, 2016) says a positive outlook is relevant to your future health. Enjoying life can reduce stress, which in turn may prolong life.

OK you get the point. Personally, I do what I say in my book, “Dr. B’s Eight Steps to Wellness” – healthy eating, no smoking, exercise, stress relief, sleep, sexual empowerment, laughter and meditation. That works for me.

Happy New Year and may you be blessed with good health, happiness and lots of love and laughter in 2017 and beyond.

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

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Bittersweet Reality About Chocolate

Sunset at Sunshine Village Ski & Snowboard Resort in Banff National Park, Alberta. (Dr. Noorali Bharwani)
Sunset at Sunshine Village Ski & Snowboard Resort in Banff National Park, Alberta. (Dr. Noorali Bharwani)

Christmas is not a good time to give you bad news about the health benefits of chocolates. I am a chocolate lover myself and I have written about the apparent health benefits of chocolates, especially dark chocolates.

Chocolate is a food produced from the cocoa bean. It is fermented, roasted, ground to form a paste of cocoa liquid that is extracted fat called cocoa butter. A mixture of cocoa paste, of cocoa butter and sugar, constitutes chocolate. Chocolate has been with us since 1700.

In general, cocoa is considered to be a rich source of antioxidants such as procyanidins and flavanoids, which may impart antiaging properties. Cocoa is also a stimulant containing theobromide and caffeine.

Panama’s Kuna people are heavy consumers of cocoa. It is reported that the Kuna people living on the islands had significantly lower rates of heart disease and cancer compared to those on the mainland who do not drink cocoa as on the islands. Is this true or just a myth? A myth, according to a report in CBC News Health (Jan 5, 2015).

Health benefits of chocolates are promoted based on antioxidants present in the chocolates. An antioxidant is a disease-fighting molecule.

Cocoa beans are rich in antioxidants. But the process to turn them into chocolate bars diminishes those disease-fighting compounds. Milk chocolate has lower levels of antioxidants than dark chocolates because the percentage of cocoa beans is lower when milk and other additives are added.

Scientists who are interested in knowing the health benefits of chocolates are not sure if increasing antioxidants levels in chocolates really has any clinical benefit.

“The whole concept behind antioxidants and whether increasing antioxidants levels in something like chocolate really has any measurable clinical benefit I think is an open question. And it’s almost like it’s being used as marketing strategy,” says Timothy Caulfield, a professor at the University of Alberta’s faculty of law and school of public health speaking to CBC News.

Caulfield says he is a chocolate lover and would be glad to see some scientific evidence supporting health benefits of chocolates.

What about cocoa flavanols?

Research suggests flavanols can relax blood vessels, improve blood flow and, increase activity in a part of the brain involved with age related memory loss. But those flavanols largely disappear once the cocoa bean is heated, fermented and processed into chocolate. In other words, making chocolate destroys the very ingredient that is supposed to make us healthy.

Mars Inc. is about to join forces with Brigham and Women’s Hospital in Boston and the U.S. National Institutes of Health in a public-private partnership to discover whether cocoa flavanols reduce the risk of heart attack, stroke and death. In a randomized controlled clinical trial, 18,000 men and women will take a high-flavanols cocoa capsule, supplied by Mars Inc., for five years. We will see if that proves anything.

In the meantime have a wonderful Christmas and Holiday Season and enjoy chocolates but in moderation.

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

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Antibiotics Aren’t Always the Answer

Al-Azhar Park in Cairo, Egypt. (Dr. Noorali Bharwani)
Al-Azhar Park in Cairo, Egypt. (Dr. Noorali Bharwani)

Are we prescribing too many unnecessary antibiotics for cold, cough and sinusitis? Yes, says an article in the Journal of the American Medical Association (Internal Medicine: May 3, 2016).

The article is titled, “Prevalence of Inappropriate Antibiotic Prescriptions Among U.S. Ambulatory Care Visits, 2010-2011,” by Fleming-Dutra, Hersh and others.

The research comes amid ongoing concern about antibiotic resistance, which has been blamed for at least two million illnesses and 23,000 deaths annually, according to the US Centers for Disease Control and Prevention (CDC).

People with sore throats, ear infections and sinus infections get the wrong antibiotic at least half the time. When that happens patients are not cured and it helps drug-resistant “superbugs” evolve, says the article.

What is the most commonly misused drug?

Zithromax, also known as “Z-Pack” or azithromycin. “Z-Pack” is a name easy to remember, so patients ask for it.

“Overall, only 52 per cent of patients treated with antibiotics for sinus infections, middle ear infections and pharyngitis (sore throat) received the first-line treatments recommended by prescribing guidelines,” Dr. David Hyun, an infectious disease specialist at the Pew Charitable Trusts, told NBC News.

Research also shows at least a third of people who get antibiotics don’t even need them. There is lot of bad prescribing of antibiotics. Ear infections, sore throats and sinus infections generate 44 million antibiotic prescriptions a year.

Antibiotics are essential to treat certain conditions. Strep throat is easily treated with antibiotics, and if a child with a middle ear infection has pus oozing out, a pediatrician will usually give an antibiotic. Sinus infections that linger may be helped with antibiotics. Experts do not disagree on that.

Quite often infection is caused by viruses. In that situation, antibiotics will not help. When an antibiotic is called for, it should be a basic one – usually amoxicillin, according to Pew researchers. However, that’s not what people usually get.

If you are allergic to penicillin and have pharyngitis then Zithromax should be tried. But Zithromax is not recommended for sinus or middle ear infection.

The reason doctors end up prescribing Zithromax is because of the pressure from patients and the convenient dosage. Not to mention sleek packaging.

To prevent misuse of antibiotics, doctors and patients should ask whether antibiotics are really necessary and if yes then what is the correct antibiotic. Medical experts have been complaining about the misuse of antibiotics for two decades, but the message still is not getting through, says one of the experts.

“Antibiotics are lifesaving drugs, and if we continue down the road of inappropriate use we’ll lose the most powerful tool we have to fight life-threatening infections,” said CDC Director Dr. Tom Frieden.

Sinusitis was the single diagnosis associated with the most antibiotic prescriptions. Drugs are not usually needed to treat sinus infections, which are often caused by fungi that are not affected by antibiotics. Up to 70 per cent of people with acute sinusitis recover without any prescribed medications, the American Academy of Allergy, Asthma and Immunology says on its website.

The point is we should use antibiotics only when we really need it. Otherwise it’s just a waste of money. And dangerous to our health.

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