The pleasures and perils of winter.

Marigot (French side), Saint Martin and the Caribbean Sea. (Dr. Noorali Bharwani)
Marigot (French side), Saint Martin and the Caribbean Sea. (Dr. Noorali Bharwani)

Winter is here! Some people have died. Some have exacerbation and/or complication of their pre-existing conditions. Some have broken bones. Some have flu. Some are depressed.

The lucky ones – if that is an appropriate word for them – are in Hawaii or Florida. Some are in Arizona or Palm Springs. Some are on a cruise in Bahamas or South America. Some are on the big mountains, gyrating down the slopes on their ultra super speed skis.

The big chill does create a new dynamics in peoples’ lives. As soon as the leaves start gathering on the ground, we are gripped with fear or joy depending on what we have planned for the snowy days.

But we carry on. Sometimes smiling, sometimes annoyed and sometimes angry. Each morning, we get ready for work in our best winter clothes. At work, the heating is on and the windows are shut. Your comfort level goes down. Your smile fades and your layers start coming off. You look out of the window for some inspiration and comfort. You see a pile of snow. You feel trapped.

Do you find this stressful? Does this affect your health?

About 50 per cent of deaths in winter are related to coronary artery disease and blood clots in the brain.

Studies have shown that most deaths occur 24 hours after cold days. This appears to be due to brief rather than prolonged exposure to cold. Resulting in rapid changes in the blood viscosity, formation of blood clot and increase demand for oxygen by heart muscles.

Those who are already known to have coronary artery disease are prone to spasm of these vessels. This further aggravates the risk of heart attacks. Asthmatics run the risk of aggravating their condition by inhaling cold air especially during exercise.

The precise mechanism of cold-induced changes is being hotly debated by the experts. Engorgement of blood vessels and release of substances which produce spasm of lung vessels are responsible for asthmatic attacks.

Patients with Raynaud’s disease suffer significant spasm of blood vessels of hands and feet when exposed to cold. This occurs mainly in young healthy women. Their blood vessels are extremely sensitive to cold or emotions.

In most of these conditions, the underlying mechanism appears to be the effect of cold on blood vessels.

Asthmatics, who want to enjoy winter sports, should keep inhalers (bronchodilators) handy at all times. People with heart problems should wear a light face mask to maintain a favorable air temperature and humidity during exertion. Warm clothings, mittens, gloves and socks should protect the rest of the body from the big chill.

Remember, better safe than sorry! We still have almost four months of winter to enjoy. Keep smiling!

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Risk of Suicide After Head Injury is High

"To jump or not to jump?" (Dr. Noorali Bharwani)
"To jump or not to jump?" (Dr. Noorali Bharwani)

Some years ago a car hit my cousin while he was crossing a street on pedestrian crossing. A driver ignored a clear sign to stop for pedestrians. Probably the driver was distracted by something he shouldn’t have been doing. My cousin had concussion and was in a hospital unconscious for several days. He recovered and went home. But he was never the same. Some years later he committed suicide.

In Medicine Hat, I think 13th Avenue is quite unsafe. It is one of the busiest streets with several businesses and seniors residencies all cramped together. Businesses like gas station, Co-op, car wash, banks, doctor’s office, dental office, golf course, Alberta Motor Association – just to name a few – are all busy with traffic going in and out of their parking lots. I think 13th Avenue is very unsafe.

If a vehicle hits you then the chances of sustaining head injury and broken bones is very high if you are lucky enough to survive. Studies have shown head injuries have been associated with subsequent suicide among military personnel.

A study from Ontario (CMAJ April 19, 2016) looked at the long-term risk of suicide after a weekend or weekday concussion. They identified 235,110 patients with a concussion. Their mean age was 41 years, 52 per cent were men, and most (86 per cent) lived in an urban location. A total of 667 subsequent suicides occurred over a median follow-up of 9.3 years, equivalent to 31 deaths per 100,000 patients annually or three times the population norm.

Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions. The paper concluded that adults with a diagnosis of concussion had an increased long-term risk of suicide, particularly after concussions on weekends.

The authors of the article suggest greater attention to the long-term care of patients after a concussion in the community might save lives because deaths from suicide can be prevented. More important and better option would be to prevent injuries to the head completely.

Last year, a movie, Concussion, a biographical sports drama thriller was released in the U.S. It is a true story based on the exposé “Game Brain” by Jeanne Marie Laskas, published in 2009 by GQ magazine. It is a true story.

Set in 2002, the film stars Will Smith as Dr. Bennet Omalu, a forensic pathologist of Nigerian origin with the Allegheny County, Pennsylvania Coroner’s Office. Omalu fights against efforts by the National Football League to suppress his research on chronic traumatic encephalopathy (CTE). A kind of brain degeneration suffered by professional football players from repeated injuries to the head.

Head injuries can be prevented. For example, heavy alcohol consumption contributes to one-third of motor vehicle collisions. Medical warnings by physicians to patients who are potentially unfit to drive are effective for preventing serious collisions. Let us make our roads safe, vehicles safe, sports safe. Let us prevent head injury, disability and death.

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Pregnancy and the Risk of Traffic Collision

Washington Monument at the National Mall in Washington, D.C. (Dr. Noorali Bharwani)
Washington Monument at the National Mall in Washington, D.C. (Dr. Noorali Bharwani)

The Canadian Medical Association Journal (CMAJ March 1, 2016) has awarded its top research honour to the authors of a study that showed women face an increased risk of serious car accidents during pregnancy.

Dr. Donald Redelmeier and his colleagues are the recipients of the Bruce Squires Award for their article “Pregnancy and the risk of a traffic crash,” which showed that pregnant drivers were 42 per cent more likely to have a serious collision that resulted in an emergency department visit. It generated the most public interest of any CMAJ research paper in 2015, says the CMAJ article.

Redelmeier’s team analyzed the health records of 507 262 Ontario women who gave birth between April 1, 2006 and March 31, 2011. The researchers found that the risk of a serious crash peaked in the fourth month of pregnancy, and was higher in the afternoon and in complicated traffic. It affected pregnant women regardless of their background, whether they had been pregnant before, or whether they were carrying a boy or a girl, says CMAJ article.

The authors concluded that pregnancy is associated with a substantial risk of a serious motor vehicle crash during the second trimester.

The World Health Organization classifies maternal deaths due to traffic crashes as coincidental and not related to the state of pregnancy. Others have argued that pregnancy is the root cause of such deaths, because pregnant women are more susceptible to crashes.

In 2014, CMAJ published a commentary (July 8, 2014) on Redelmeier’s research. The title of the commentary was “High risk of traffic crashes in pregnancy: Are there any explanations?” The commentary touched on several likely explanations. Here is the summary:

  1. Driving requires a high level of concentration and cognitive ability to maintain and complete a number of complex tasks. If there is any impairment in the driver’s cognitive ability, there may be an increased risk of a crash.
  2. The physiologic changes of pregnancy have been shown to increase fatigue and sleep deprivation in pregnant women.
  3. Prospective study using self-reported questionnaires showed that sleep length began to decrease during the second trimester and quality of sleep worsened during pregnancy.
  4. Maternal stress is also a common feature of pregnancy.
  5. Drivers who experience sleep deprivation, stress or fatigue will have an increased risk of a car crash.
  6. If busy urban areas are harder to navigate and require greater concentration in driving, then fatigue, tiredness and stress are likely to have a greater impact on the risk of a crash in urban areas.

There is no doubt studies have shown an increased risk of motor vehicle crashes among women in their second trimester of pregnancy.

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Is it Safe for Pregnant Women to Drive?

A lonely tree at Police Point Park, Medicine Hat, Alberta. (Dr. Noorali Bharwani)
A lonely tree at Police Point Park, Medicine Hat, Alberta. (Dr. Noorali Bharwani)

I found an interesting article in the Canadian Medical Association Journal (CMAJ July 8, 2014) regarding the above subject. Dr. Donald Redelmeier and his colleagues author the research paper titled, “Pregnancy and the risk of traffic crash.”

When a woman is pregnant there are a number of changes occurring in the body. These changes may contribute to increased driving error. The authors of the CMAJ article compared the risk of a serious motor vehicle crash during the second trimester to the baseline risk before pregnancy.

The authors analyzed women who gave birth in Ontario between April 1, 2006, and March 31, 2011. Certain groups of women were excluded from the study. The primary outcome was a motor vehicle crash resulting in a visit to an emergency department.

After analyzing all the data from the study, the conclusion was that pregnancy is associated with a substantial risk of a serious motor vehicle crash during the second trimester. The authors further suggested that this risk merits attention for prenatal care.

In a commentary associated with the article under the title, “High risk of traffic crashes in pregnancy: Are there any explanations?” Stephen J. McCall, and Sohinee Bhattacharya say that the World Health Organization classifies maternal deaths due to traffic crashes as coincidental and not related to the state of pregnancy. Others have argued that pregnancy is the root cause of such deaths, because pregnant women are more susceptible to crashes.

McCall and Bhattacharya make the following key points in their CMAJ commentary:
-Normal physiologic changes during pregnancy may increase sleep deprivation and stress, which may increase the likelihood of human error.
-Epidemiologic studies have shown an increased risk of motor vehicle crashes among women in their second trimester of pregnancy; these studies should be interpreted with caution because data on duration and frequency of driving, and on shared responsibility for crashes, were lacking.
-Further research into the biological mechanisms that may link pregnancy to car crashes is warranted.

So, like many things in medicine the jury is still out debating whether we should allow pregnant women to drive, especially during second trimester. Suffice to say whether you are male or female, pregnant or not, just drive carefully.

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