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What is New About Carpal Tunnel Syndrome?

Sunset in the prairies. (Dr. Noorali Bharwani)
Sunset in the prairies. (Dr. Noorali Bharwani)

August seems to be my favourite month. Many good things and some not so good have happened during this month. One of the good things was starting this column 16 years ago. A by-product of these columns has been publication of my two books. Hopefully, there will be more.

OK, let us get back to what we are going to discuss today – carpal tunnel syndrome.

Last time I wrote about carpal tunnel syndrome was in 2003. This is a good time to review the subject again as I saw an article in the Canadian Medical Association Journal (CMAJ August 5, 2014).

Carpal tunnel syndrome was first described in 1853. It is a common, painful disorder of the wrist and hand. It is caused by pressure on the median nerve in the wrist. The median nerve travels from the forearm into the hand through a “tunnel” in the wrist.

The CMAJ article says the condition is not as common as thought. “A prospective long-term study of a general working-age population (16 to 74 yr) showed that the overall incidence of carpal tunnel syndrome over a 66-month period was 103 per 100 000 people per year,” says the article.

Who is at risk?

Individuals who are working in areas where there is exposure to excess vibration, use of increased hand force and repetitious movements increase the risk of carpal tunnel syndrome. In an analysis of 37 studies it was found that factors significantly associated with increased risk included vibration, increased hand force and repetition.

What about somebody spending many hours using computer keyboard?

The authors of the article say that the association between carpal tunnel syndrome and use of a computer keyboard or mouse is unclear. The authors reviewed eight epidemiologic studies and came to the conclusion that the evidence is insufficient to confirm that computer work causes carpal tunnel syndrome.

The review also found no evidence of an association with repetitive, low-force noncomputer work.

Personal characteristics that increase a patient’s risk include increase in age, sex (women were at higher risk than men) and obesity.

Is there a good treatment for carpal tunnel syndrome?

After 160 years, one would think we would have found a good treatment for this ailment. Let us see what we have.

Initial management may include occupational therapy and wrist splinting. A study found that eight weeks of splinting and education sessions with an occupational therapist was helpful in 63 per cent of the patients. These patients did not require surgery.

These patients showed improvement in symptom severity, functional status, pain perception and grip strength. The article says if symptoms do not improve within eight weeks, referral to a surgical specialist should be considered.

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Listeria Infection and the Food We Eat

Birds In Love (Dr. Noorali Bharwani)
Birds In Love (Dr. Noorali Bharwani)

On July 19, 2014, Wawona Packing Company of Cutler, California voluntarily recalled certain lots of whole peaches (white and yellow), nectarines (white and yellow), plums and pluots packed between June 1, 2014 and July 12, 2014 due to the potential for contamination of the products with Listeria monocytogenes.

This was a precautionary action. Reports indicate to date, no illnesses have been linked to this recall. The health providers are advised to keep Listeria in mind when anybody presents with symptoms such as high fever, severe headache, stiffness, nausea, abdominal pain and diarrhea.

Patients presenting with these symptoms should be asked if they have been exposed to Wawona Packing Co.’s fresh whole peaches, plums, nectarines, and pluots. For patients with illness suggestive of invasive listeriosis, testing should include blood culture and other tests, such as culture of cerebrospinal fluid, as indicated by the clinical presentation.

According to New York State Department of Health (NYSDOH) Bureau of Communicable Disease Control (BCDC), to date, no illnesses have been linked to the recalled fruits. So, that is good news.

The Canadian experience:

According to Health Canada website, the listeriosis outbreak in the summer/fall of 2008 linked to ready-to-eat meats produced at a Maple Leaf plant in Ontario was a significant public health event. As of December 10, 2008, there were 20 deaths across five provinces where listeriosis was the underlying or contributing cause of death and the outbreak generated high media and public interest.

The bacteria are found in food and elsewhere in nature. It can cause a rare but serious disease called listeriosis. Pregnant women, the elderly and individuals with weakened immune systems are at higher risk than others. In serious cases, listeriosis can lead to brain infection and even death.

Listeria is found in soil, vegetation, water, sewage, some types of livestock feed and in the feces of humans and animals. Animals and humans can carry the bacteria without knowing it.

Plants and vegetables can become contaminated with Listeria from soil, water and manure-based fertilizers. Farm animals that appear healthy may also carry Listeria and contaminate foods such as meats and dairy products.

The Health Canada website says that unlike most bacteria, Listeria can survive and sometimes grow on foods being stored in the refrigerator. Moreover, foods that are contaminated with these bacteria look, smell and taste normal. About five per cent of healthy adults are carriers of Listeria and have no symptoms. The good news is Listeria can be killed by pasteurization and proper cooking procedures.

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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Six Distinct Types of Inherited Disorders Affect Several Parts of the Body

Rabbit preparing to cross the road. (Dr. Noorali Bharwani)
Rabbit preparing to cross the road. (Dr. Noorali Bharwani)

The title of this column may sound strange and you may not have heard of this condition before. That is because it is not a common problem. It is called Ehlers-Danlos syndrome (EDS). EDS is known to affect men and women of all racial and ethnic backgrounds.

EDS is a group of inherited connective tissue (bones, joints, skin) disorders, caused by various defects in the synthesis of collagen. Collagen is the main structural protein that gives strength to various connective tissues in animals. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25 to 35 per cent of the whole-body protein content.

Individuals with EDS have disorders marked by extremely loose joints, plastic like loose skin that bruises easily, brittle bones and easily damaged blood vessels. There are six distinct types of EDS currently identified. Each type is thought to involve a unique defect in connective tissue, although not all of the genes responsible for causing EDS have been found.

How common is Ehlers-Danlos syndrome? According to some literature, the exact numbers are difficult to estimate. It is believed the combined prevalence of all types of this condition may be about one in 5,000 to 40,000 individuals worldwide. There are many sub-groups of the condition that are hard to estimate.

First description of EDS was by Hippocrates in 400 B.C. In 1657 a Dutch surgeon noted a case history of a boy with very lax skin. The first association of very mobile joints to skin was published in 1892 in Moscow by A.N. Chernogubov. In 1901, Edvard Ehlers and in 1908 Henri-Alexandre Danlos described different disorders involving joints and skin with bruises. In 1936, the disorder was named Ehlers-Danlos syndrome.

Treatment is based on the symptoms. Unfortunately, there is no specific cure. Individuals with EDS generally have a normal life span. Their intelligence level is normal. Those with the rare vascular type of EDS are at greater risk of rupture of a major organ or blood vessel. These individuals have a high risk of sudden death.

What do we know about genes and mutation?

A gene is a unit of heredity that is transferred from a parent to offspring and is held to determine some characteristic of the offspring. Mutation is a natural process that changes a DNA sequence. And it is more common than you may think.

As you know genetic disease is caused by an abnormality in an individual’s genetic material. The abnormality can range from minuscule to major. It occurs from a discrete mutation in a single base in the DNA of a single gene to a gross chromosome abnormality involving the addition or subtraction of an entire chromosome or set of chromosomes. Sounds complicated?

Some genetic disorders are inherited from the parents, while other genetic diseases are caused by acquired changes or mutations in a preexisting gene or group of genes. Mutations occur either randomly or due to some environmental exposure. A gene mutation is a permanent change in the DNA sequence that makes up a gene. Well, this is a short introduction to genetics.

If you have a family history of EDS and are planning to have children then you should seek genetic counseling. You can learn more about EDS from the Ehlers-Danlos National Foundation website.

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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There are Significant Technical Advances in Heart Surgery

Bird, looking for something? (Dr. Noorali Bharwani)
Bird, looking for something? (Dr. Noorali Bharwani)

I met a gentleman who has had a stroke, suffers from coronary artery disease and has a malfunctioning aortic valve – a valve in the left lower chamber of the heart from where the blood is pumped out to the rest of the body.

I also read in my book (Dr. B’s Eight Steps to Wellness – page 90) that the heart muscle is the hardest-working muscle in the body. It pumps out 60 milliliters of blood at every heartbeat. Every day, the heart pumps out at least 10,000 liters of blood. The heart has the ability to beat over three billion times in a person’s life. Isn’t that something?

The heart is like a grand central station. If the central station breaks down then all the lines come to a stop. We don’t want that. So we need to keep our heart healthy. But if you are unlucky like the gentleman I mentioned earlier, then you have to look for medical and/or surgical help.

Pursuing a healthy life style in terms of regular exercise, healthy eating and no smoking is a good thing. If you inherit bad genes then you have to increase your efforts to prevent the disease. If you need medications then your good doctor will help you with that.

There are surgical options for coronary artery disease. If putting stents in plugged vessels does not help then surgical treatment is required. Coronary artery bypass graft (CABG) surgery has become a routine procedure.

The majority of coronary surgical procedures are performed for multiple vessel disease. Overall, the mortality rate of coronary artery surgery is low, at around two to three per cent, although this benefit is offset by a complication rate of 20 to 30 per cent. It is important to evaluate various physical, psychological and social side effects of CABG as well.

Now the technology has improved to a point where patients with more advanced coronary artery disease and extensive coexisting conditions are taken care of. “Off-pump” procedures, in which the heart does not have to be stopped, were developed in the 1990s. These patients generally have fewer complications, less leg pain, and shorter hospital stays.

Options for treating damaged aortic valve are many. The valve can be repaired or replaced in many ways. In the United States, surgeons perform about 99,000 heart valve operations each year. Valve replacement is most often used to treat aortic valves in the left lower chamber of the heart. Your surgeon may choose a mechanical valve, which is usually made from materials such as plastic, carbon, or metal. Mechanical valves are strong, and they last a long time.

Your surgeon may choose a biological valve, which is made from animal tissue or taken from the human tissue of a donated heart. The procedure may be open-heart surgery or the new technique of minimally invasive valve surgery thorough small openings in the chest wall. In some cases, minimally invasive valve surgery can be done using a robot.

Minimally invasive surgery cannot be done in patients who have severe valve disease, have clogged arteries or are overweight.

Research shows around two per cent of people treated with aortic valve replacement will die in the first 30 days after surgery. However, the risk of death from surgery is far lower than that associated with not treating severe aortic disease.

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