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Leg Ulcers can be Prevented After Deep Vein Thrombosis and Post-Thrombotic Syndrome

Kin Coulee Park in Medicine Hat has more than one thing to offer. (Dr. Noorali Bharwani)
Kin Coulee Park in Medicine Hat has more than one thing to offer. (Dr. Noorali Bharwani)

The title of this column suggests three interrelated health issues – deep vein thrombosis, which may lead to post-thrombotic syndrome, and in some cases the individual may end up with chronic leg ulcers.

Deep vein thrombosis (DVT) is the formation of a blood clot in a deep vein, usually in the legs. Post-thrombotic syndrome is a complication of DVT and can affect 23 to 60 per cent of patients in the two years following DVT of the leg. Of those, 10 per cent may go on to develop venous ulcers.

The presentation of DVT and post-thrombotic syndrome may be quite similar. Seventy to 90 per cent of chronic leg ulcers are due to improper functioning of venous valves of the legs. It is important to remember post-thrombotic syndrome is a chronic but preventable condition. Otherwise it leads to limb pain, swelling, skin discolouration, ulceration, and rash after DVT.

An article in the Canadian Medical Association Journal (CMAJ January 7, 2014) describes the risk factors for the post-thrombotic syndrome, which include older age, obesity, male sex, iliofemoral (proximal) DVT, recurrent same side DVT, previous or primary venous insufficiency, and elevated D-dimer levels after withdrawal of anticoagulant agents.

Any individual who has had DVT should be advised regarding the long-term consequences of damaged valves in the deep veins and preventive measures. These include using compression stockings and taking low-molecular-weight heparin for at least three months after DVT is diagnosed.

Compression stockings and exercise therapy are first-line treatments for the symptoms of post-thrombotic syndrome.

A Cochrane review reported that compression stockings (30 to 40 mm Hg) used early after the diagnosis of DVT were associated with a 69 per cent reduction in the odds of post-thrombotic syndrome developing.

A systematic review also showed that long-term treatment with low-molecular weight heparin after DVT resulted in a lower incidence of post-thrombotic syndrome than treatment with anticoagulants administered orally.

The aim of management is to prevent further incidence of DVT and prevent long-term consequence in the form of chronic leg ulcers, which are not easy to treat.

An article in the American School of Laughter Yoga website titled, “Laughter helps leg ulcers heal.” quotes Dr. Andrea Nelson, University of Leeds School of Healthcare saying, “Believe it or not, having a really hearty chuckle can help too (with leg ulcers). This is because laughing gets the diaphragm moving and this plays a vital part in moving blood around the body.”

Once again, remember, more you laugh the better you get and better you feel.

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Common Cold has a Large Impact on Society and Health Care System

A goose family heading home for supper at Echo Dale Provincial Park recently. (Dr. Noorali Bharwani)
A goose family heading home for supper at Echo Dale Provincial Park recently. (Dr. Noorali Bharwani)

A doctor finished examining a man in his office.

“It’s just a common cold,” he announced, “There is no cure, and you’ll just have to live with it until it goes away.”

“But, Doctor,” the patient complained, “it’s making me so miserable.”

The doctor rolled his eyes toward the ceiling. Then he said, “Look, go home and take a hot bath. Then put a bathing suit on and run around the block four times.”

“What!” the patient exclaimed, “I’ll get pneumonia!”

“Exactly,” the doctor replied, “We have a cure for pneumonia.”

This joke is from Ryan Murphy found on the Internet.

In 1931, an article in the Canadian Medical Association Journal (CMAJ) on the common cold said, “The common cold is so common that we are apt to pass it by with a contemptuous gesture, unless, of course, we are the sufferers ourselves.”

The illness is very costly in terms of direct medical costs and indirect costs owing to missed work because of illness or caring for an ill child.

The common cold is an acute, self-limiting viral infection of the upper respiratory tract involving the nose, sinuses, pharynx and larynx.

The virus is spread by hand contact with secretions from an infected person or aerosol of the secretions and virus. The incubation period varies but is just under two days for rhinovirus.

Symptoms typically peak at one to three days and last seven to 10 days, although they occasionally persist for three weeks. Symptoms can be mild to severe.

The incidence of the common cold declines with age. Children under two years have about six infections a year, adults two to three and older people about one per year.

Stress and poor sleep may increase the risk of the common cold among adults, whereas attendance at a daycare center increases the risk among preschool children.

The symptoms and signs of the common cold overlap with those of other conditions like allergic rhinitis, sore throat, sinusitis, ear infection and influenza. If you have these symptoms then you should see your doctor.

How can we prevent common cold? A Cochrane systematic review of 67 studies of various types was looked at. The majority of results suggested that physical preventive measures such as hand washing reduced the risk of getting or spreading upper respiratory tract infections.

When I have a cold, I lie on the sofa for three days and sleep a lot. On the fourth day I feel better. I am ready to go to work. It’s like magic.

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Making Sense of Celiac Disease and Non-Celiac Gluten Allergy is Not Easy

Gordon Wright waiting for birds to fly by so he can take pictures in Police Point Park on a beautiful spring afternoon in Medicine Hat. (Dr. Noorali Bharwani)
Gordon Wright waiting for birds to fly by so he can take pictures in Police Point Park on a beautiful spring afternoon in Medicine Hat. (Dr. Noorali Bharwani)

“Celiac disease is common and is associated with other immune diseases,” says an article in the Canadian Medical Association Journal (CMAJ January 8, 2013).

The symptoms of celiac disease are triggered by gluten (a protein found in wheat, rye, barley and triticale) in people who are genetically susceptible. Triticale is a hybrid of wheat and rye first bred in laboratories during the late 19th century.

Ten things to remember about celiac disease as summarized from the CMAJ article:

  1. A first-degree relative with celiac disease has a 10-fold increased risk of acquiring the condition. It affects one in 133 North Americans.
  2. The risk is increased among people with autoimmune thyroid disease (three to five per cent), type one diabetes mellitus (five to 10 per cent) and Down syndrome (5.5 per cent).
  3. Gluten perpetuates the destruction of villi in the small intestine. Intestinal villi are small, finger-like projections that help in digestion.
  4. The disease can develop at any age.
  5. Clinical symptoms can be diverse from abdominal pain to diarrhea, weight loss and malnutrition.
  6. Screening for celiac disease is recommended for people who have associated symptoms, an associated condition or a family history of celiac disease.
  7. The most widely available test is the tissue transglutaminase IgA antibody test, which has an estimated 95 per cent accuracy rate. If antibody testing is negative and celiac disease is suspected, the IgA level should be measured.
  8. All adults with an abnormal screening result should undergo a small-bowel biopsy to confirm the diagnosis of celiac disease.
  9. Because of an increasing awareness of celiac disease, people may choose to adopt a gluten-free diet before diagnostic testing. That is not the right way to manage the problem. Further diagnostic testing should be performed following a medically supervised gluten challenge of at least four weeks, with sufficient gluten to produce symptoms.
  10. Treatment is lifelong adherence to a gluten-free diet. Examples of gluten-free grains are oats, buckwheat, millet, rice and quinoa. Gluten-free diet reduces the risk of complications such as osteoporosis and intestinal lymphoma.

Is there an illness called non-celiac gluten sensitivity?

Yes. You have symptoms of celiac disease but it cannot be confirmed. Then you may have non-celiac gluten sensitivity.

An article by Sapone et al. (BMC Medicine 2012) titled, “Spectrum of gluten-related disorders: consensus on new nomenclature and classification,” says in only 10 years, key milestones have moved celiac disease from obscurity into the popular spotlight worldwide.

What has generated more interest is the spectrum of illnesses associated with ingestion of gluten. These are: 1. Allergy to wheat 2. Autoimmune celiac disease, dermatitis herpetiformis and gluten ataxia 3. Possible immune-mediated gluten sensitivity.

Research estimates that 18 million Americans have non-celiac gluten sensitivity. That’s six times the amount of Americans who have celiac disease. Researchers are just beginning to explore non-celiac gluten sensitivity.

These individuals seem to be sensitive to gluten often also experience headaches, rashes and fatigue. It is possible that it may in fact be other proteins or sugar in wheat (other than gluten) that may be triggering the reaction. There is no inflammation or damage to the intestinal lining as in celiac disease. More research is needed to understand this problem. Did I hear you say, “If only things in life would be simple and straight forward?”

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Are you afraid to eat food cooked in a microwave oven?

Ducks enjoying the beautiful spring sunshine. (Dr. Noorali Bharwani)
Ducks enjoying the beautiful spring sunshine. (Dr. Noorali Bharwani)

I met a lady who said she does not own a microwave oven and does not eat anything cooked in it. She believes it is not healthy. So I went on the Internet looking for some information.

First I checked the World Health Organization website. It has a document on the safety of microwave ovens dated February 2005 (WHO Fact Sheets 182 and 183). It concludes by saying, “Food cooked in a microwave oven is as safe, and has the same nutrient value, as food cooked in a conventional oven. The main difference between these two methods of cooking is that microwave energy penetrates deeper into the food and reduces the time for heat to be conducted throughout the food, thus reducing the overall cooking time.”

Microwaves are high frequency radio waves and, like visible radiation (light), is part of the electromagnetic spectrum.

Microwave ovens cook food with waves of oscillating electromagnetic energy. The energy is similar to radio waves but move back and forth at a much faster rate. The microwave oven energy is more penetrating than heat that emanates from an oven or stovetop. It immediately penetrates and reaches molecules about an inch or so below the surface.

The food cooked in a microwave oven does not become “radioactive”. Nor does any microwave energy remain in the cavity or the food after the microwave oven is switched off. It is like turning on and off a light bulb. Once it is turned off no light remains.

Is it safe to stand close to a microwave oven while it is turned on?

I tend to walk away from the microwave oven while it is turned on because I feel I am being exposed to radiation. I thought I would have less wrinkles on my face (and look younger) if I did that. I learnt microwave ovens are designed to prevent people being exposed to microwaves while the oven is on. A person 50 cm from the oven receives about one one-hundredth of the microwave exposure of a person five cm away.

Finally, I will have the Harvard Medical School website (June 2008 update) have the final word, “A marvel of engineering, a miracle of convenience – and sometimes nutritionally advantageous to boot.” It is talking about the microwave oven. You can say the same thing about the person who cooks your wonderful meal everyday. So, don’t complain, enjoy!

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