News from Doc Grimes

State of Health on PEI

2012-03-16T13:36:00Z

The Chief Health Officer for Prince Edward Island, Dr Heather Morrison, has published the first public report of health on the island. It is a good read, and well worth the trouble. I have excerpted a section of the executive summary for a quick overview.

Health Trends

The Health Trends section is presented in four sub-sections: demographics, health status and determinants, common & chronic conditions, and communicable diseases. In this document, Islanders are commonly compared with the entire Canadian population as an assessment of how different or how similar PEI rates are with the national rates.

Below is a summary of the key findings within each sub-section.

Demographics

PEI, similar with Canada and many other countries worldwide, has an aging population- Based on current projections by the year 2020, 1 in 5 Islanders will be over the age of 65. By 2040, 1 in 3 Islanders will be over the age of 65.
Male Islanders born in 2007 are expected to live for 78 years and female Islanders for 83 years, both are similar to Canadian expectancies. Life expectancies have been slowly increasing over time and Canada boasts one of the highest life expectancies in the world.
Cancer, heart disease and stroke are the leading causes of death in both PEI and Canada.
Fewer low birth weight babies are born in PEI compared to Canada and this rate has remained stable over time.
PEI's education levels, similar to Canada's, are improving.
PEI's average annual income per person has risen over the past ten years but still remains lower than Canada's.
The unemployment rate in PEI has decreased since the early 1990's but remains consistently higher than the Canadian rate.

Health Status & Determinants

Almost two-thirds of Islanders and 60% of Canadians report their health as very good or excellent.
The majority of Islanders and Canadians report their mental health as very good or excellent.
Islanders are less likely than Canadians to consume 5 or more fruits and vegetables per day.
Breastfeeding initiation rates have steadily increased over time, but still have room for improvement.
More Islanders are likely to be obese than Canadian counterparts.
PEI and Canada have similar rates of children and young adults who report being either overweight or obese.
Islanders are less likely to be physically active than Canadians.
More Islanders report heavy drinking than Canadians and this has not changed over time.
The same proportion of Islanders report daily smoking as Canadians. This rate declined between 1995 and 2005 and has remained stable since that time.
Fewer Islanders are exposed to second hand tobacco smoke in public places compared to Canadians.
Over half of all Islanders intend to do something to improve their health in the next year. The overwhelming majority intend to get more exercise.
More Islanders report a strong sense of belonging to their community compared with other Canadians.

Common & Chronic Conditions

Islanders are more likely to suffer from "any chronic condition" (arthritis, asthma, heart and stroke, diabetes or cancer) than Canadians overall.
Prostate (males), breast (females), lung and colorectal cancer are the most common cancers diagnosed in both PEI and Canada.
Islanders (aged 50 to 74) are less likely than their Canadian counterparts to be screened for colorectal cancer by either FOBT or colonoscopy/sigmoidoscopy. In 2011, the FOBT screening program was expanded Island-wide for all Islanders 50-75 years of age.
A similar proportion of Islanders and Canadians are living with Type II diabetes which is more likely to occur in males and rises considerably after age 45.
One in every 5 Islanders has been diagnosed with hypertension. Hypertension is more likely to occur in females.
One in every 10 Islanders has been diagnosed with asthma which is more prevalent in our younger population.
The proportion of Islanders being diagnosed with COPD has been increasing since 2000.

Communicable Diseases

The most common sexually transmitted infection in 2010 in PEI was Chlamydia which accounted for over 75% of all sexually transmitted and bloodborne infections. Over two thirds of reported chlamydia cases occurred in people aged 20-29 years.
Influenza was the most common vaccine preventable disease in PEI during the 2010-2011 influenza season. Age and sex were evenly distributed. Almost 50% of individuals who had lab-confirmed influenza were hospitalized. It is well established that the number of lab-confirmed cases greatly underestimates the actual number of influenza cases.
Among enteric, foodborne and waterborne illnesses, Campylobacteriosis accounted for 39% of all reported cases, followed closely by Salmonellosis (37%) and parasitic infections (17%). Over 60% of the Salmonellosis cases were S. enteritidis which was the first time this serotype was that predominant in PEI.
The number of new Hepatitis C cases in PEI increased between 2009 and 2010. This increase was paralleled with an increase in Hepatitis C testing.
In total 5 cases of Pertussis were reported in 2010. This increasing trend has been seen in all parts of North America. To enhance efforts to protect Island infants from pertussis, a Cocooning Strategy has commenced across the province that provides Pertussis (dTAP) vaccination for new mothers post-delivery in the hospitals, and additional close contacts (e.g. father, grandparent, nanny etc) through Public Health Nursing. This strategy aims to prevent adults from transmitting pertussis to their infants.

Conclusions

Over the past century, improvements in health and quality of life have made Canada one of the healthiest nations in the world. This report provides comparisons with the rest of Canada and comparisons over time on a number and range of indicators. In many areas PEI is similar to the rest of Canada and has shown improvement over time. Islanders enjoy a similar life expectancy to the rest of Canada and the majority of us report our overall health as very good or excellent.

However, there are some areas which are concerning and require attention. It is no surprise that we are an ageing population and as we age our risk of having one or more chronic diseases increases. Having a chronic disease can interfere with lifestyle, sense of wellbeing, and limit opportunity for independence. While some risk factors like ageing and genetics are inevitable, many risk factors can be modified or changed. Such modifiable risk factors include being overweight or obese, being physically inactive, and smoking. While smoking rates have remained stable since 2005, Islanders are more likely to be obese or overweight, than the rest of Canada. As well Islanders are less likely to be physically active than the rest of Canadians. It is daunting to think that children today may be the first generation to see a declining life expectancy due to increasing risk factors such as obesity and lack of physical activity, which inevitably contributes to the earlier onset of chronic diseases such as Type II Diabetes and high blood pressure. In addition to concerns about increasing chronic diseases is the challenge faced by well established public health programs. Declining immunizations rates in a population can lead to resurgence of diseases such as mumps, measles, and pertussis which have previously been controlled.

The good news is that more than half of Islanders indicated they plan to do something to improve their health in the next year, with the majority indicating they plan to become more physically active. As well, Islanders report a strong sense of belonging to their community which is an important aspect of mental health and social wellbeing. Both of these factors may have a protective affect against life's stressors. Individuals taking action at any time to improve health, whether it is to stop smoking, increase physical activity, or having a child immunized, will contribute to healthier communities over time.

Moving Forward

The role of public health includes developing and influencing public policy to ensure the population is as healthy as possible as well as preventing injury, illness, and premature death. This is accomplished through education and awareness, public health programs such as immunization and food protection, and gathering and reporting accurate and timely information to support program and policy decisions.

Priorities for the CPHO going forward include:

1) Maintaining a strong focus on Health Protection programs which are legislated under the Public Health Act, including Food Protection, Immunization and Communicable Disease surveillance and follow up.

2) Improving immunization rates of children to ensure better protection against vaccine preventable diseases. It is also a priority to increase awareness regarding adult immunization.

3) Maintaining a robust surveillance system in order to appropriately inform program and public health policy development.

4) Working with partners within the Department of Health and Wellness, other government departments and all Islanders towards attaining healthy weights. This includes working to improve breastfeeding rates and developing a provincial breastfeeding policy.

5) Working with Islanders in collaboration with our partners, particularly health promotion, to address the significant burden that high rates of chronic diseases such as heart disease, cancer and diabetes place on our society. Our primary focus must be to prevent and reduce the rates of chronic diseases.

Again, this is just a summary of the entire report, and I would encourage you to take the time and review it.

For a review of this report from the island newspaper, see the Guardian.

Doctor Grimes, I am just too old to exercise.....

2012-02-25T21:56:46Z

Exercise has no age limitsOne of the things I love the most about my practice in rural Prince Edward Island is that I have the pleasure of taking care a a large number of independent folks in the 80+ age bracket (and not a few in the 90+ age bracket). These are folks living on their own, keeping themselves active, and having a wonderful life. I think about these patients often, they are an inspiration, and they remind me that you are never ‘too old’. In fact, it has me thinking about how effective exercise is in patients that are older, and the truth of the mater is, you are never to old to exercise (an excellent review of the subject Clin Geriatr Med. 2011 February).

What good could exercise possibly do for me now that I am 90? A key to living on your own as you age is to avoid ‘frailty’. Believe it or not, there is a medical definition of frailty. Dr Buchner ( Clin Geriatr Med. 1992 Feb) proposed the definition and Dr Fried further defined the elements(J Gerontol A Biol Sci Med Sci. 2001 Mar.). In short it s the combination of at least three of the following: exercise intolerance or easy fatigue, weakness, slowed motor performance, loss of physical activity, and unintentional weight loss. If you meet this definition you are more likely to die, to fall and break a hip, have heart disease, and be hospitalized (Am J Med. 2005 Nov). Exercise has shown the ability to reverse almost all of these elements of frailty (it does not help with the weight loss). In two studies looking at frail patients, exercise at least twice a week seemed to reverse the components of frailty (J Am Geriatr Soc. 1999 Sep and J Am Geriatr Soc. 2000 Oct).

Ok, exercise might be good, but it can’t possibly work all that fast.....So, let’s take a look at a couple of studies to see how quickly things seemed to work. In the first study it took place over 9 months and involved strength training and walking with the goal of having frail men reach 78% of their peak heart rate. There was a 14% increase in their endurance over the course of the study (J Appl Physiol. 2003 Nov). A second study looked at frail women and had them exercise using an stationary bike for 12 weeks. These women improved their aerobic capacity by 30% and increased their quadriceps (thigh muscles) mass by 12% (Am J Physiol Regul Integr Comp Physiol Epub 2009 Aug 19).

Well it might improve my endurance but I am still afraid of falling... Thankfully, exercise also seems to help with this most dreaded fiend. Ask anyone who is older and fear of falls will be in their top ten worries of life, and with good reason. Falling has a definite impact on quality of life and longevity of life (Annu Rev Public Health. 1992;13 and MMWR March 31, 2000/49(RR02);1-2). Improving muscle strength can be accomplished through resistance training (JAMA. 1990 Jun 13;263(22):3029-34, Med Sci Sports Exerc. 2001 Sep, J Gerontol A Biol Sci Med Sci. 2004 Jan, and Cochrane Database Syst Rev. 2009 Jul 8;(3):CD002759). Even if you have declined so much that you are in a nursing home, strength training can improve your health (N Engl J Med. 1994 Jun and Arch Phys Med Rehabil. 1998 Jan). It is the improvement in strength which is the bedrock for improved balance and fewer falls.

So how much do I need to do? There are various guidelines available, but the fundamental guide of 150 minutes a week is the one that is most recommended that is 20 minutes a day (Am Fam Physician 2010 Jan). By performing 20 minutes of exercise daily you can decrease the risk of early death, heart disease, stroke, diabetes, elevated cholesterol, and some cancers. Additionally, exercise has been shown to decrease the likelihood of dementia (Ann of Internal Med 2006 Jan).

Where can I learn more about starting to exercise more?

The Centers for Disease Control and Prevention has an excellent resource on Physical Activity for Health Aging.

Here are two goog handouts form the American Family Physician (here and here).

My toe hurts so bad it must be gout!

2012-02-24T16:00:24Z

Devilish Gout

I clearly remember this photo from the medical school lecture on gout. The image a a demon chewing on the toe of the suffering patient was lasting. In my clinic, often times, this picture is unfortunately only too true. Many people come in with this demon chewing away. Often it is not just the one toe, and in some cases, it is lots of joints.

It hurts like the devil, so what causes it? The short answer is urate crystals in excessive amounts (for the long answer look here Ann Intern Med 2005 Oct 4;143(7):499). Urate is common in the body, and as long as there is not too much of it, things go on pretty smoothly. However, when there is too much, then it can start to form crystals and these are very irritating. These crystals tend to form on locations that are a little cooler (such as toes and fingers) and under greater pressure (such as the big toe). An individual may either make to much urate or get rid of it too slowly, either way it leads to excess.

It never happened before, why did it happen now? There are several ‘risk factors‘ associated with the development of gout. Like many other diseases, gout is linked to obesity, weight gain, and over consumption (especially alcohol, sugary soft drinks, seafood, meat) as well as high blood pressure and some of the medications we use to treat high blood pressure (Arch Intern Med 2005 Apr 11;165(7):742 , BMJ 2008 Feb 9;336(7639):309 , N Engl J Med 2004 Mar 11;350(11):1093 and Lancet 2004 Apr 17;363(9417):1277). The blood pressure medications that are the most likely contributors include diuretics (the water pills), beta-blockers (like metoprolol or carvedolol), ACE inhibitors (rampart, lisinopril, fosinopril) and some angiotensin II receptor blockers (except losartan). This is a shame since these are all really good medications for treating high bold pressure, but there it is (BMJ 2012 Jan 12;344:d8190).

Besides hurtin’ is there anything else ‘gout’ can do? By far the most debilitating aspect of gout is the pain. However, when folks with gout are observed over time, it seems to be associated with reduced life expectancy (J Epidemiol 2000 Nov;10(6):403). It is not clear if this is due to the complicating conditions that give rise to increased risks of gout, or gout itself.

Ok, so how do I know if it is gout? Usually, the sudden onset of extreme pain in a single joint without any recent trauma is all the history that is needed to make gout the number one item on your diagnostic list. The pain usually begans and peaks in 24-48 hours and if we don’t do anything else, it will resolve in 3-14 days (Rheumatology (Oxford). 2007 Aug;46(8):1372-4. Cleve Clin J Med. 2008 Jul;75 Suppl 5:S22-5. .and Cleve Clin J Med. 2008 Jul;75 Suppl 5:S5-8.). The pain may be so intense that you cannot tolerate putting anything (even bed linen) on the affect part. It is classically the big toe, but can affect any joint. The gold standard for diagnosis remain examination of some joint fluid under a microscope and finding the little gout crystals (and also rule out infection as the cause). It is also helpful to take a blood sample and see if the urate is elevated.

If it goes on long enough then a build up of urate in the joint may cause it to bulge and potentially leak out (warning images may be a bit graphic fingers with tophi and surgical removal of thophi). As things settle down and we look back on the history, often a precipitating event may be identified (such as new medication, recent infection, change in diet, or such).

So how do we treat it? Treatment falls into two camps, acute and prevention. Treating the acute attack is really important (especially if you are the one with gout), and it consists of reducing the inflammation. So, the steps to reduce inflammation include anti-inflammatory medications such as NSAIDs (like indomethacid) or steroids. The traditional treatment has been colchicine but data indicates that it works slower than NSAIDs (Rheumatology (Oxford) 2007 Aug;46(8):1372). The treatment usual needs to run for about two weeks. The second phase of treatment is prevention. This includes weight loss, improving your diet, and possibly medication to lower the urate levels. All of this should be started about two weeks after the attack has settled down. There is some question as to whether or not the medication really decreases the frequency of the attacks. The medications work by increasing the the amount of urate that is filtered out through the kidney.

Here is where you can get more information

American College of Rheumatology

Patient UK

National Institute of Arthritis and Musculoskeletal and Skin Diseases

American Family Physician

Arthritis Foundation

Doc, why do my hands and feet tingle so much? Doc, why do my hands and feet tingle so much?

2012-02-19T18:42:09Z

Foot with pins and needlse from http://neuropathy911.com/

Doc, you know my hands seem to tingle an awful lot. And you know, so do my feet. It is like they are asleep or something. Any idea what that is?

So, the sense of tingling is called parasthesia, and might represent any number of things. It usually represents an irritation or inflammation of a nerve, such as when your legs fall asleep while sitting cross legged. Sometimes it feels like tingling, and sometimes it feels like a burning. The pattern or the tingling, the characteristics of the tingling and the presence or absence of weakness help us figure out the cause.

What kind of things may make this happen? There are lots of causes of peripheral neuropathy. This can range from trauma, infection, or endocrine problems. Trauma (chronic or acute) can lead to trapping of nerves that causes chronic irritation, inflammation and may lead to neuropathy. Carpal tunnel syndrome is the classic example of this kind of problem. This could also be due to problems with diabetes or thyroid dysfunction. Nutritional deficiencies also account for some of the cases, usually due to problems with B12 absorption as seen in patients with celiac disease, renal disease, or liver disease (Lancet 2004 Jun 26;363(9427):2151). In these instances, the irritation/inflammation of the nerves is as a consequence of the disease progress. There are also other causes (such as infections), from medications (alcohol, chemotherapy drugs, and others), or from toxins (arsenic, mercury, cyanide and such).

Ok, so how do I figure out if I have this problem or not? This is pretty straight forward for us. The first step is a good history and a thorough physical examination. Often these two steps will do a great deal to help figure out what is going on. The history and physical will help us narrow down the likelihood of peripheral neuropathy and point us in the direction of the tests that will need to be considered to determine the cause. The American Academy of Neurology has laid out a straight forward stepwise evaluation of peripheral neuropathy (Neurology 2009 Jan 13;72(2):185). The basic screening tests include a test for diabetes, B12 deficiency and serum protein immunofixation electrophoresis. Additionally, testing the nerves themselves using a nerve conduction test is usually performed (Neurology 2003 Mar 25;60(6):898).

OK so if I have this, what do I need to do to treat it? Well, this is a case of prevention being far better than treatment. First off, activity is not likely to make things worse and helps people maintain strength (Cochrane Database 2004 Oct 18;(4):CD003904). For patients who have pain as the main symptom of their unhappy nerves, then there are several medications that have been shown to help with the control of the pain. Narcotics (such as morphine and such) have been shown to decrease the pain from neuropathy (Cochrane Database Systemic Review 2006 Jul 19;3:CD006146). Additionally, there are some older antidepressant medications are helpful in decreasing the pain from neuropathy (Neurology 2003 Apr 22;60(8):1284). Of course, if the cause is vitamin deficiency then treating that deficiency will help correct the neuropathy.

Where can I get some more information?

The National Institute of Neurological Disorders and Stroke has lots of information here.

MedlinePlus also has a lot of good information.

Hey Doc…..Is it alright if I run while I am pregnant?

2011-11-09T19:14:06Z

You would be surprised at the number of answers that are given to this question. The traditional thought was a categorical NO, but in the past several years views have begun to change. The American College of Obstetricians and Gynecologists has changed their tune with regard to exercise during pregnancy as of 2002. So let’s take a look at the question a little closer.

Will it do me any good to exercise when I am pregnant? The short answer is yes. It appears that regular exercise improves fitness (Cochrane review 2010) and it decreases the risk of having an overly large baby (Obstetrics and Gynecology 2009). Additionally it decreases the likelihood of gestational diabetes (Diabetes Care 2011) and for women who have gestational diabetes is appears to improve their diabetes control (Diabetes 1991 and American Journal of Obstetrics and Gynecology 1989). It appears that exercising regularly may decrease some of the third trimester discomforts (Medical Science of Sports Exercise 1995) and daily yoga decreases labor discomfort (Complimentary Therapies in Clinical Practices 2008) and reduces stress (International Journal of Gynaecology and Obstetrics 2009).

Are there any problems with exercising while pregnant? There are some theoretical concerns regarding the potential to decrease the blood supply to the placenta and baby, preterm labor and potential trauma. Studies looking into this have yielded varying results. Here are several studies that look at the effects of exercise and possible effect of low birth weight (here, here, here, here, and here). Some studies show that exercise does not change birth weight (here, here, here, here, and here). And yet another shows that it might increase birth weight (here). In a large study that reviewed 18 prior studies it did not appear that exercise had a significant effect on maternal weight gain, birth weight, length of pregnancy, length of labor, or scoring of the infant at birth (Medicine and Science in Sports and Exercise 1991).

What do I need to know to exercise safely? There are some very clear reasons NOT TO exercise and these are absolute: Pregnancy induced hypertension, Premature rupture of membranes, Incompetent cervix (or having had the surgery to keep the cervix closed), persistent second or third trimester bleeding, a baby that is not growing very well, preterm labor in this or a prior pregnancy (ACOG 2002). Additionally, if you have heart disease, uncontrolled high blood pressure, uncontrolled kidney disease, profound anemia, or uncontrolled diabetes you are probably better off without the exercise while you are pregnant. Generally the exercise you were doing prior to pregnancy can be continued. Here are some specific guidelines from DynaMed:

sedentary women - walking, bicycling, stair climbing, aerobic dance, water aerobics or swimming for 65-75% of maximum heart rate for 30 minutes 3 times/week
recreational athletes/regular fitness exercisers - same as above plus running/jogging, dance, tennis at 65-85% of maximum heart rate for 30-60 minutes 3-5 times/week
elite athletes - same as above plus some competitive activities depending on gestational age at 75-85% of maximum heart rate for 60-90 minutes 4-6 times/week

And of course, it goes without saying that you should probably avoid certain high risk activities such as contact sports (boxing, field hockey, football, rugby, ice hockey, martial arts, rodeo, soccer, wrestling), high risk sports (scuba diving, hang-gliding, parachuting, rock climbing, power lifting) and overly strenuous exercise that might lead to dehydration or hyperthermia.

For more information look to the American Academy of Family Physicians here and here.

Cervical Cancer and HPV Vaccine

2011-10-23T16:00:00Z

By Tanya Gallant MSII Northern Ontario School Of Medicine

What is cervical cancer?

Cervical cancer is when the normal cells in the cervix grow out of control and have an ‘abnormal’ appearance (Canadian Cancer Society, 2009). Women whose cervical cancer is found and treated early typically do quite well. This stresses the importance of finding the cancer early.

In Canada, 1300 new cases of cervical cancer will be diagnosed in 2011 and the chances of a women developing cervical cancer is 1 in 153 (Canadian Cancer Encyclopedia, 2011).

Approximately 350 women in Canada will die from it this year (Canadian Cancer Encyclopedia, 2011).

What are the common signs of cervical cancer?

It is important to note that many women do not feel any symptoms at first, but the most common symptom that women experience is bleeding from the vagina. Bleeding may happen after sex, between menstrual cycles, and after menopause (Canadian Cancer Encyclopedia, 2009).

Is there a test for cervical cancer?

Yes, there is! There is a test called the ‘Pap test’ that is used to screen women for cervical cancer. Women who are 18 years old or who are sexually active should get screened (Canadian Cancer Encyclopedia, 2011). Once you go to your appointment to see your doctor, he/she will take a look at the walls of your vagina by using a thing called a speculum. The testing part is by taking a painless swab of cells from the cervix (hence, cervical cancer) and sending them to the lab to have them checked under a microscope.

If the cells are normal, women normally are checked every 1 to 3 years until the age of 69 or until the doctor finds something abnormal (Canadian Cancer Encyclopedia, 2011).

If the cells are abnormal, the doctor will have you come back to see whether follow-up testing is needed (Canadian Cancer Encyclopedia, 2011).

A new cervical cancer test is being considered on PEI to replace the test just mentioned. It will test for both cancer and the human papillomavirus (discussed later). It is currently being tested in Newfoundland and Labrador, New Brunswick and Ontario (CBC, 2011).

How do we treat cervical cancer?There are three main ways that we treat cervical cancer (Canadian Cancer Society, 2009):

- Surgery

- Radiation therapy

- Chemotherapy

After a person has had treatment for cervical cancer, they will need to be checked from time to time to see if the cancer has come back or if the cancer has spread.

How can I prevent cervical cancer?

The human papillomavirus vaccine is now available.

What is HPV?

HPV stands for the human papillomavirus. It is spread by skin-to-skin contact and sex (CDC, 2009). HPV causes up to 70 percent of cervical cancers (CBC, 2011).The risk of getting HPV increases with the number of sexual partners you and your partner have had.

If HPV is so common, why should I be concerned?

The majority of the people infected with HPV fight off the virus within two years of getting it, typically without treatment (CDC, 2009). Unfortunately, a small amount of people cannot seem to get rid of the virus. In these people, there is a greater chance that HPV will turn into cancer. This stresses the importance of getting tested regularly.

What is the HPV vaccine?

At the moment, two types of vaccine are available: Gardasil and Cervarix (Public Health Agency of Canada, 2010).

Gardasil is given by three different vaccine shots, which are given two and six months after the first. It protects against HPV types 6 and 11, which cause 90% of genital warts, as well as HPV types 16 and 18, which are high-risk types and cause about 70% of cervical cancer (Gardasil, 2010).

Cervarix is also given by three different vaccine shots, which are given one and six months after the first. It protects against HPV types 16 and 18, which cause 70% of cervical cancer (Cervarix, 2010).

Who should get the HPV vaccine?

The HPV vaccine in the US is recommended for all girls and women between the ages of 9 and 26 years (Public Health Agency of Canada, 2010). Both vaccines work best if given before a person starts having sex because the vaccine does not get rid of it once you have it. The vaccine may still give some protection to those who are under the age of 26 and sexually active, as well as have genital warts, a positive HPV test, and/or an abnormal Pap test (Public Health Agency of Canada, 2010).

Where can I get more information?

Your health care professional is your best person of contact for any questions or concerns you may have.

The Canadian Cancer Society has a great user-friendly website on cervical cancer that can be found by pushing this link: http://www.cancer.ca/Canada-wide/About%20cancer/Types%20of%20cancer/What%20is%20cervical%20cancer.aspx

The Public Health Agency of Canada has a great site on the safety and effectiveness of the HPV vaccine: http://www.phac-aspc.gc.ca/std-mts/hpv-vph/fact-faits-vacc-eng.php

Concussions and Post Concussion Syndrome

2011-10-19T16:16:13Z

By Adam Kading MSIV Dalhousie Medical School

Concussions have become a mainstream topic in recent years. Here in Canada we have constant exposure to news of concussions. It seems like every week during the hockey season, another player has been sidelined with post concussion syndrome. Of course, concussions do not occur only in the setting of sports. This article will shed some light on exactly what concussions are, how to manage them, and why symptoms can persist.

What is a concussion?

The brain is protected inside the head by the thickest bony structure in the body, the skull. The skull does a remarkable job protecting the brain from injury. However, when force from injury is severe (for example: a bad fall, car crash, or having a shoulder collide with your head) the brain smashes against the inside of the skull producing injury. In most cases the injury causes unseen damage to the nerves of the brain, or bruises in the brain matter. In more severe injuries, bleeding inside the skull and brain death can occur. Thankfully, severe injuries like this are much less common, tend to be associated with the severity of injury, and produce recognizable symptoms.

What are the symptoms of concussion?

The most common immediate effects of a concussion are loss of consciousness, confusion, and amnesia (forgetting the event). However, not everybody will experience these and they are not necessary for diagnosis. Common symptoms occurring minutes to hours after a concussion are headache, dizziness, nausea and vomiting, fatigue, difficulty concentrating, and memory problems. Sometimes people will experience emotional changes days to weeks after an injury. Anxiety, depression and post traumatic stress disorder occur frequently after head injury. Occasionally personality changes can be seen. If you are experiencing any of these symptoms or if you have had a head injury you should see a doctor in a timely fashion.

Symptoms that can indicate that a severe brain injury has occurred are difficulty waking the person, seizures, vomiting many times, an obvious skull fracture, and weakness or numbness in the body. If these symptoms are occurring in yourself or someone you know, call 911 or get to an emergency room right away!

How long will symptoms last and what is Post Concussion Syndrome?

Post concussion syndrome refers to symptoms of concussion that persist after the trauma has occurred. Common symptoms include headache, dizziness, difficulty concentrating, persistent fatigue, irritability, and mood changes but the range of symptoms is extensive and includes the ones listed above and more. These symptoms tend to be brought on or made worse with anything that stresses the brain. This includes talking, reading, watching TV or exercising. The vast majority of people with first time head injuries will improve after approximately one week. In these people the injuries to the nerves of the brain heal without permanent damage. Most others will be back to normal by 3 to 6 months. Approximately 10 % of people will still be experiencing symptoms at 1 year. A small number of people can be left with permanent symptoms and disability. Unfortunately it is difficult to predict who will have long lasting symptoms as length of symptoms is not necessarily associated with the severity of the injury. It is believed however, that post concussion syndrome lasts longer in people who have experienced multiple past concussions.

How do we manage concussions?

Unfortunately there are no great medical treatments to improve concussion symptoms. An injury to the brain is treated in much the same way as an injury to any other part of the body. If you break your arm you need to rest your arm until complete healing has occurred. The same general idea holds true for the brain. Immediately after a concussion the brain needs rest. It is recommended that for the first one or two days after a head injury that you rest in a quiet room. This means no stimulation. No reading, no TV, no conversations, no stress. You should sleep as much as needed. Frequently people are concerned by the need for extra sleep following a concussion. This is actually a normal and expected consequence of an injury. The brain heals best when sleeping.

It used to be common practice to recommend waking a person with a concussion every several hours following injury, the general idea being that family members might be able to pick up on a serious injury. This is no longer recommended. It is difficult for family members to assess a sleepy person and it likely only contributes to anxiety while not allowing the injury sufferer the time to heal. That being said, the concussion sufferer should be checked on regularly. If there are concerns regarding breathing or how they are sleeping they should be woken up and checked out by a doctor.

After you no longer have symptoms at rest you can slowly resume activity. The essential rule is start low and go slow. Basic activities like walking, talking, light chores, and reading can be attempted. If any of these activities bring on symptoms mentioned above, then the activity needs to be stopped. You have pushed your self too far and need to return to rest. You need to resume light activities slowly and need to learn how long you can engage in them before experiencing symptoms. If symptoms are experienced after 20 minutes of walking, walk fifteen minutes next time and gradually increase this amount day to day.

Over time the light activities can progress to more intense activities such as exercising or returning to work/ school. The same principle applies here as to the other stages. If these activities bring on symptoms then return to lighter activities and do less the next time. If returning to a contact sport, then contact should be resumed only after you are symptom free after performing significant amounts of intense exercise.

There are many guidelines available on managing concussions. The link below was published by Think First and is geared towards contact sports, but the first several stages can be applied to anyone with a head injury. Think First Concussion Handout

Long term outlook

The general outlook for people with mild concussions is good. Most will improve within 1 week and the vast majority will be back to normal by 6 months. If your symptoms have lasted longer than a year there is a chance that some symptoms will be permanent. Repeated concussions can cause several problems. The more concussions you have had, the longer post concussion symptoms will tend to last. People who experience many concussions over their life like boxers or other pro athletes are prone to dementia. This includes permanent forgetfulness, chronic headaches, loss of concentration and personality changes.

Important Points

1. If playing sports and an athlete experiences a head injury they need to be removed from play immediately. This is to reduce the likelihood of experiencing a second concussion. Back to back concussions can cause second impact syndrome, a rare but fatal complication where the brain swells inside the skull.

2. It is essential that you be symptom free before returning to sports or normal day to day activities. One reason for this is to avoid the second impact syndrome mentioned above. Another reason is that ignoring post concussion symptoms can make them last longer. Finally, returning to play while still experiencing symptoms makes a second concussion more likely. You can get a concussion with less head trauma than normal if you still have post concussion symptoms.

3. Be aware of feelings of anxiety or depression. Mood symptoms frequently occur in people with long term post concussion symptoms. This is thought to occur due to injury to the brain and also due to the lifestyle changes that inevitably occur. If you are feeling irritable, on edge, depressed, not sleeping well, having flashbacks, or having bad dreams see your doctor.

Works Cited

CMA Policy. Head Injury and Sport. Publication. Ottawa: CMA, 2011.

DeKosky, Steven T., Milos D. Ikonomovic, and Sam Gandy. "Traumatic Brain Injury — Football, Warfare, and Long-Term Effects." New England Journal of Medicine 363.14 (2010): 1293-296.

Fann, J. R. "Psychiatric Illness Following Traumatic Brain Injury in an Adult Health Maintenance Organization Population." Archives of General Psychiatry 61.1 (2004): 53-61.

Kissick, J. "New Concussion Management Guidelines: Concussion Question and Answer Document For Physicians." Think First, June 2005.

Putukian, Margot. "The Acute Symptoms of Sport-Related Concussion: Diagnosis and On-field Management." Clinics in Sports Medicine 30.1 (2011): 49-61.

Think First. "CONCUSSION: GUIDELINES FOR PATIENTS, FAMILY MEMBERS & CAREGIVERS." May 2007.

Prostate Cancer Screening: To screen or not to screen…

2011-10-12T15:26:25Z

By Daniel Keefe MSI Dalhousie Medical School

What is the prostate?

The prostate is a gland found only in men that is about the size of a walnut. It is found just below the bladder and surrounds the urethra (the tube that brings urine to the penis when urinating). It produces fluid that helps make up semen. Naturally as men age, the prostate gland will grow in size.

The Facts about Prostate Cancer

Prostate cancer is the most common cancer in Canadian men (1 in 7 will be diagnosed in their lifetime) (Prostate Cancer Facts). Prince Edward Island has the highest occurrence rate of prostate cancer in Canada, and it is the second leading cause of cancer related death (behind lung cancer) among Canadian men (PEI Cancer Stats 2011).

Alright you have my attention now. How can I avoid developing prostate cancer? How do I know if I’m at risk?

Healthy lifestyle habits such as regular exercise, not smoking and minimizing how much salt and fat you eat can lower your risk of developing prostate cancer. African-Canadian men and men with close relatives (father or brother) that developed this cancer before age 65 are at increased risk.

How would I know if I had prostate cancer?

Prostate cancer is a very slow growing cancer and that symptoms may only develop after years of tumour growth. Essentially, it is possible to have prostate cancer without ever having any symptoms. It is for this reason that screening is important to discuss even without symptoms. However, some symptoms attributed to prostate cancer include: urinating more frequently, waking to urinate at night, having to strain to urinate, not feeling ‘empty’ after urinating, and difficulty initiating urination. It is important to realize that these symptoms may be caused by other health problems (e.g., infection) and do not mean you have prostate cancer. If you are experiencing any of these issues be sure to go see your doctor (TOP-PROCAP Clinical Practice Guidelines).

Screening for Prostate Cancer – Ask your Doctor!

The goal of screening is to detect cancer before it rears its ugly head. It is important to discuss getting screened for prostate cancer even if you don’t have any symptoms.

You should discuss screening with your doctor if you are:

- Over the age of 50

- At a high risk of developing prostate cancer (a strong family history of this cancer or if you are African-Canadian)

- Or, if you are concerned about developing prostate cancer

If you choose to undergo screening, there are two recommended screening measures which should be used in combination: the digital rectal examination (DRE) and prostate-specific antigen (PSA) test.

DRE: this exam is used to directly examine the prostate by inserting a gloved and lubricated finger into the rectum. Your doctor can check your prostate for any abnormal lumps or an increase in size of the prostate, which would warrant further investigation.

PSA: the prostate produces a protein that is present in the blood of all men. By sampling your blood, the quantity of this protein (PSA) can be measured. If the quantity of the protein in your blood is higher than normal for your age group it is an indicator for potential prostate abnormalities. A high PSA does not mean you have prostate cancer as infections, or benign growths can also increase your PSA numbers. (Patient Education)

What if I have a positive screening test?

If either of these tests is abnormal you may be referred to see a physician who specializes in this area, known as a Urologist. Using an ultrasound-guided needle, the urologist will sample the cells of the prostate to diagnose or rule out prostate cancer. This is known as a Trans-Rectal Ultrasound (TRUS) guided prostate needle biopsy.

How often should I get screened for prostate cancer?

If you have a normal DRE and PSA test you can be tested every two years. If you have a normal DRE and a slightly elevated PSA it is important to recheck your PSA levels yearly to monitor progression.

What you need to know before getting screened. The great debate!

The fact is most people will die with prostate cancer and not from it! In other words, although many men will be diagnosed with prostate cancer, it will not cause their death. Prostate cancer screening is the centre of a continuing debate of its benefits. Let us discuss the pros and cons (Interesting article):

Pros:

- The PSA test is a good predictor of prostate cancer risk (higher PSA value means a higher risk of prostate cancer)

- Earlier detection of prostate cancer leading to better treatment options and outcomes

- Regular PSA tests and DREs can monitor the progression of prostate cancer in those that have been diagnosed but where treatment is not warranted as of yet

Cons:

- Prostate cancer is being detected in more men leading to overtreatment of disease that may never cause any problems in a man’s lifetime.

These treatments include radiation therapy and radical prostatectomy (surgery to remove the prostate).

The risks of these treatments are significant: incontinence (inability to control urination and possibly constant leaking), impotence (inability to achieve erection) and rectal dysfunction have huge impacts on a man’s quality of life

- High rates of false-positives. In other words, patients may have a positive test when the patient does not have prostate cancer

- Screening may suggest no cancer in a patient that does have cancer (false-negative) which gives patients a false sense of security

- More screening leads to more biopsies putting patients at increased risk of infections, blood in urine and pain.(Cochrane Library 2006)

The bottom line:

Prostate cancer screening is a beneficial tool to detect disease in the earliest and most treatable form. However, statistics from the largest trial analyzing this screening has shown that we would have to screen 1410 men before saving a single life due to this disease. Some perspective: there are approximately 25,000 men over the age of 50 in PEI. We would have to screen each of these men every 2 years for 10 years to prevent the death of 17 men.

Furthermore, because it is such a slow growing cancer, screening of men not expected to live more than 10 years does not have any benefit and should be avoided. (European Randomized Study of Screening for Prostate Cancer (ERSPC) trial).

More information about screening can be found here and here.

An article that provides examples of the risk of Prostate Cancer screening from the Huffington Post

Teachers and Lessons

2011-09-02T10:34:53Z

Not every teacher is human, not ever question answerable.

Some lessons are learned after the teacher has left.

So, this thing on my chest, it has gotten bigger and darker, should it come off?

2011-07-11T20:26:57Z

OK, you have this mole on your chest that you have been watching for a while, and suddenly it starts to change, how do you know when it is time to remove it? How can you tell if it is something worth worrying about? What if it is a melanoma? Today we are going to talk about just that.

What is a Melanoma? A melanoma is a skin cancer that grows out of the cells in your skin that have color (melanin) in them. These are the same skin cells that get darker as you tan. After repeated intense irritation these cells can develop into cancers. There are four distinct types based on how they grow and spread, and it is this growth and spread that make them so dangerous.

70% are superficial spreading melanomas that spread out, slowly enlarging, becoming irregularly shaped with variations in color prior to growing deeper.
15% are nodular melanomas that spread deep quickly and are usually blue-black, with occasional ulcerations
10% are acrolentiginous and mucosal melanomas that occur on the palms of the hands and soles of the feet as well as the nail beds and lips/nose on the moist surfaces. These can occur in people of any skin color at equal rates, and grow outward first and then deep.
5% lentigo maligna melanoma with is in the sun exposed areas (90% face, neck, back of hands, lower legs) in older patients with variable coloration and slow expansion followed by increasing depth

Ok, so who gets these things? These are cancers that occur as we get older (30-60 years old) and with the exception of the acrolentiginous type, occur primarily in light skinned individuals (Archives of Internal Medicine 2006 and International Journal of Cancer 2010). The sun appears to be important for causing these cancers, and it is the intense sun that causes burns that seems to be the worst offender (Dermatology Surgery 2006). Also, the number of freckles that you have increases your risk of melanoma (although it is not clear if this increases the risk, or makes them harder to find (Journal of National Cancer Institute 2003). Finally, the use of tanning beds is associated with the increased risk of developing melanoma (Journal of American Academy of Dermatology 2005).

I have a lot of freckles, how do I know if one is going bad? Dermatologist use the ABCDE rule to help us figure this out. This simple rule looks at several aspects of a lesion to help (Journal of the American Medical Association 2004)

A is for asymmetry. Is the mole in question symmetric, that is, if you split it in half would both sides look the same?

B is for border. Is the border of the mole sharp and regular? Or is it shaggy and irregular?

C is for colors. Are the many colors in the mole? Is this mole differing shades of brown, black, gray, or white?

D is for diameter. Is this mole bigger than 6 mm (the size of a pencil eraser)?

E is for evolution. Has this mole changed in the recent past? Is it getting bigger? Changing color? Bleeding? Starting to itch or hurt?

These are the signs to watch for to help you figure out if it is a mole that warrants a closer look, and by a closer look, that means a biopsy. The only way to know for sure if a mole is a melanoma or not is to cut it out and examine it under a microscope. IT is by looking at the mole under to microscope that both he accurate diagnosis can be made, and the severity of the melanoma can begin to be judged. It is most important for a melanoma to know how deep it goes, this is a key to knowing what should be done to treat it.

Ok, so if it is a melanoma can it be cured? Well that all depends on how deep it goes. The key element to cure is finding the melanoma early and cutting it out before it gets deep enough to spread to other places. If it is thin enough, then the biopsy itself may be curative. In many cases a repeat surgery is performed to take out a wider margin of healthy tissue to reduce the chance of spread. For folks unfortunate enough to have a melanoma that goes deeply, there are many new drugs that seem to hold a lot of promise for treatment, but again the key is finding them early.

So, the key element is finding these things early, and that takes vigilance on your part, and the part of the medical team. If you are at high risk, then it is worth your time to come in and be seen. Having a close inspection of your skin on a regular basis is probably prudent if you are at high risk. Of course, it should go without saying that protection from the sun is intensely helpful.

For more information on melanoma, please check out the following web sites.

The American Society for Dermatologic Surgery has a good self examination kit available

The American Academy of Family Medicine has several good handouts of melanoma, checking for skin cancer, and prevention of sun damage.

Next week a guest article on Prostate Cancer.

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