Published in July 2005 in The Ottawa Citizen

With summer approaching, an understanding of summer heat upon the human body can help prevent heat-related illnesses.

The body has four means of dissipating heat: conduction, evaporation, radiation and convection.

Conduction is the transmission of heat through a substance like blood, water or other tissues. The muscles, warm from exercise, can dissipate heat directly to the skin surface. Blood can absorb great quantities of heat from the muscles and other tissues. It will return to the heart and then circulate to the small blood vessels in the skin. During exercise, the blood vessels dilate to allow greater quantities of blood to transfer heat to the skin surface.

The skin will radiate heat into the surrounding air and environment just like a space-heater. Sweat on the skin surface can absorb the heat and evaporate to reduce body temperature.

As the air warms around the body, it will rise. Cooler air moves in to replace it and absorbs body heat. This cycle is called convection and explains why fans help cool us.

Each mechanism works best within a specific temperature range. At temperatures less than 20ºC, radiation, convection and conduction will dissipate most generated body heat. Above 20ºC, evaporation of sweat is the primary means of heat dissipation.

Children do not sweat as much as adults and produce more heat for the same level of activity. They need to generate greater levels of heat before they do sweat.

Overweight individuals do not dissipate heat as well compared those of normal weight. The elderly have a decreased thirst response, and a reduced ability to circulate blood to the skin surface. Their blood vessels do not dilate as well as younger adults.

Certain medications can contribute to the risk of heat illness.

As temperature and humidity increase, evaporation becomes less effective. On a hot city day, core body temperatures increase because of radiant heat  from the sun’s and hot concrete surfaces.

Evaporation accounts for 85 percent of heat loss during vigourous exercise (a 70 kilogram athlete can lose one to two litres of sweat per hour). Failure to replace water and salt loss further compromises conduction and evaporation.

Adapting to the effects of heat during exercise over a specific time is termed acclimatization. This allows one to adapt to the increased demand to dissipate heat. Fluid replacement is essential for this process to work.

The five types of heat-related illness from mild to severe are; heat swelling (edema), heat cramps, fainting from heat (heat syncope), heat exhaustion and heat stroke.

Heat edema occurs in people who have not undergone acclimatization. Fluid leaks out into the tissues of the feet especially when standing for prolonged periods. Leg elevation reverses this process.

Heat cramps are painful abdominal, arm or leg muscle spasms occurring when too much salt and water is lost. This is a warning sign of pending heat exhaustion. Drinking water, juice or sport drinks and eating salty foods will relieve the cramps.

If there is no cool-down period after exercise, fainting is a risk. Blood pressure can drop when quickly transferring from a sitting to standing position. Dehydration worsens heat syncope. Lying flat with legs elevated rapidly reverses this condition.

Heat exhaustion occurs with excessive sweating in a hot humid environment. Body fluid volume is lost. The core body temperature increases from 38ºC to 40.5ºC. Symptoms include profuse sweating, fatigue, headache, dizziness, visual disturbances, lack of appetite, nausea, vomiting, vertigo, chills, muscle weakness, rapid heart rate (tachycardia), low blood pressure (hypotension) and skin flushing.

The person must be moved to a cool area. Applying cool water-soaked cloths helps. Elevate the legs. Those who are alert need one litre of oral fluid replacement per hour for two to three hours. Disoriented or unresponsive people require emergency treatment. All need a thorough medical evaluation at the hospital.

Heat Stroke is the most severe form of heat-related illness. Body temperature exceeds 40.5ºC and leads to multi-organ damage and failure. Altered mental status is a critical determinant of heat stroke. This medical emergency needs prompt evaluation and treatment.

Preventing heat-related illness is straightforward.

• Stay in air conditioning if possible.
• Drink lots of water before, during and after any outdoor activity.
• Avoid drinks with caffeine or alcohol. They will increase fluid loss via urination.
• Increase the amount of time you spend outdoors every day little by little.
• Take frequent rest breaks while outdoors on hot days.
• Avoid direct sunlight and stay in the shade when possible.
• Wear light-colored, loose-fitting, open-weave clothes.
• Avoid activities that require helmet use.
• Try scheduling activities or workouts early in the morning or late evening. Avoid heavy outdoor activity between 10 a.m. and 6 p.m.

Enjoy your summer.

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Originally published in The Ottawa Citizen March 11, 2005

The thrill of the winter sojourn to warmer climes and ocean activities like scuba diving, surfing and snorkeling, among others, can lead many to overlook other notable health and safety precautions.

If you’re heading south for some fun in the surf, remember the ocean is an alien world with creatures that, for all their beauty, can be a literal shock to the system.

What do you do when stung by a jellyfish, step on a sea urchin’s spine, encounter the whip of a stingray’s tail, or eat a poisonous fish?

Certain reef fish like grouper, king mackerel, sturgeon and snapper can ingest microscopic organisms called dinoflagellates either directly or by eating smaller fish. One particular species, gambierdiscus toxicus, produces a toxin that becomes increasingly concentrated as it travels up the food chain.

Thousands of people eating these fish found around Hawaii, Florida, Puerto Rico and the U.S. Virgin Islands can develop Ciguatera (seeg-wha-terra) poisoning. The severity of poisoning depends on the fish size and the number of exposures. The classic symptom found in 80 per cent of patients is a cold sensation reversal, where hot sensations are perceived as cold and vice versa.

Gastrointestinal and neurological symptoms usually begin one to six hours after ingestion and last seven to 14 days, and in some cases months to years. They include nausea, vomiting, watery diarrhea, abdominal pain, numbness, vertigo, severe weakness, muscle aches, slowed heart rate (bradycardia), low blood pressure (hypotension), diffuse pain and decreased vibration and pain sensations.

There is no immediate cure, only symptom relief. Cooking, freezing, salting or smoking the fish does not deactivate the toxin. If these fish are eaten, avoiding eating the fish’s internal organs like the liver because the toxin concentrates in these areas.

Travellers to Hawaii and California who eat tuna or mackerel may develop scombroid. Poor handling and refrigeration of the fish can cause a buildup of histamine and histamine-like substances within the dark meat. The person develops symptoms 30 minutes after ingestion. Symptoms can last about eight hours and include flushing, nausea, vomiting, diarrhea, severe headache, palpitations, abdominal cramping, dizziness, dry mouth, hives, and red eyes.

Treatment includes the use of antihistamines administered by mouth, intravenous or into the muscle, depending on symptom severity.

Encounters with jellyfish are memorable. Their long tentacles have stinging cells, or nematocysts, that sting. Nematocysts found on amputated tentacles and dead jellyfish will sting as well.

Symptom severity depends on the number of stinging nematocysts, the toxicity of the venom and each person’s unique reaction. The poison is destructive; it damages skin, red blood cells, heart tissue and nerves.

The most common symptom is local pain followed (in order or likelihood) by a “pins and needles” feeling (paresthesias), nausea, headache, chills and, rarely, cardiovascular collapse or shock. Symptoms can last up to three days.

Treatment focuses on pain relief and controlling neurologic symptoms. Use gloves or forceps to remove any visible tentacles. Avoid touching towels used to wipe off the nematocysts; they will sting. A 30-minute application of vinegar (five per cent acetic acid) will stop any remaining nematocysts on the skin from releasing their venom. Salt water is a good substitute if vinegar is unavailable. Never use fresh water because it will stimulate venom release.

Scraping the nematocysts off the skin using shaving cream and a razor is another solution. There are reports that cold and hot packs can help sooth the pain.

Stepping on a sea urchins’ toxin-coated spines will cause pain and burning and occasional skin discolouration lasting about 48 hours. The spines will break if you try to remove them by hand. Fragments will remain embedded in the skin and can cause infection. Surgical removal and wound debridement may be necessary.

The stingray’s venomous spine is at the end of its tail. The venom will reduce blood flow to the affected limb causing tissue death and destruction, poor wound healing and infection.

Intense pain is immediate and can be accompanied by salivation, nausea, vomiting, diarrhea, muscle cramps, shortness of breath, seizures, headaches, muscle cramp and cardiac arrhythmias. Fatalities are rare.

Bleeding from the puncture site is controlled by direct pressure to the wound. Hot water soaks will help reduce the pain.

Wound care includes thorough rinsing of the affected area with fresh water. Patients should check for redness and swelling at the site; a sign of infection. Sometimes, part of the spine will remain embedded in the tissue; surgical removal may be necessary.

A tetanus shot may be required for stingray and sea urchin stings. Although fatalities are rare for all these toxic reactions, prompt recognition of the symptoms can lessen the discomfort and morbidity.

© Dr. Barry Dworkin 2005

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Originally published in The Ottawa Citizen January 09, 2005
Original Title: Toxic Soup

All the ingredients for a potential health calamity are present

The tsunami survivors face great health challenges. To date there have not been reports of epidemics of cholera or other infectious diseases. However, the massive aid pouring into the affected regions is designed to address the health risks that have the potential to cause further harm.

All the ingredients for a potential health calamity are present: a contaminated water supply, lack of sanitation infrastructures, overcrowding, malnutrition, and endemic infectious diseases.

Human waste and decaying corpses contribute to the massive contamination. In effect, some of the survivors are living amongst a biologic toxic soup containing myriad pathogenic micro-organisms.

It is the children who will suffer most. Their weakened state impairs their ability to resist disease. Many can live without food for a week or more, but survival time is measured in days without clean water; they will rapidly succumb to dehydration, especially within the hot tropical environment.

With weakened immune systems comes an increased incidence of diarrheal illnesses, pneumonia, urinary tract infections and skin infections, among others. The severity of the illness and the survival rate is usually proportional to the time it takes to diagnose and treat it.

Indeed, bacterial diseases such as typhoid (Salmonella typhii), cholera (Vibrio cholerae), and enterotoxigenic E. coli are a major cause of dehydration, and are endemic in developing countries in Asia and Africa. All these organisms are found in contaminated food and water. They will also pass from person to person. Lack of adequate shelter makes it impossible to isolate the sick from the uninfected population.

Although the manner in which they cause disease (pathogenesis) differs, the end result is similar: They will infect and damage the intestines (enteric disease).

The small intestine absorbs most of the nutrients from food while the large intestine absorbs about 99 per cent of all water that flows through it. Damage to these structures can lead to bleeding and reduced absorptive capacity causing massive diarrhea.

Children and the elderly do not have as great a fluid reserve as do younger adults. In many instances, they must receive intravenous fluid replacement to compensate for their losses from diarrhea. The availability of clean water to drink will not help them in this case because the large intestine has lost its ability to absorb it.

The supportive care to treat cholera and other enteric diseases requires many litres of intravenous fluid replacement per patient. Some may need between 10 and 20 litres during the course of disease. Given the thousands of people that will contract these diseases, the resources alone for this one condition can strain available medical resources and supplies.

Contaminated pools of water attract disease-carrying flies, malaria and dengue fever-laden mosquitoes, and also harbour hepatitis A.

Without adequate shelter and netting for nighttime protection, the survivors are at risk for malaria and dengue fever. Left untreated, many will die. Waterborne parasites can also cause intestinal infection leading to cramps, bleeding and diarrhea. Most healthy people will recover from hepatitis A without any major consequences. However, the survivors of the tsunami have a greater risk of complications because of their weakened state.

Tuberculosis, a disease that affects two billion people worldwide — roughly one-third of the world’s population, most in developing countries — will claim more victims. This highly contagious person-to-person disease will have the opportunity to infect many others because of the living conditions and migration of people to temporary shelters or camps.

Some will have physical injuries that require proper wound care. Without treatment, these wounds will fester and infections will develop. Cellulitis is a common and potentially serious skin infection that normally starts in areas where there is pre-existing skin damage. The skin becomes swollen, red and hot and has a poorly defined border. The area of redness (erythema) rapidly expands and creeps along the skin within hours.

If diagnosed early, treatment consists of an oral antibiotic. Intravenous antibiotics are used if oral treatment fails or if there is an initial extensive spread of the infection. However, many of the survivors will not have access to prompt medical treatment. The end result is that a readily treatable infection will spread and increase the risk of septic shock and death.

The relief efforts are designed to counter the problems outlined, here. Setting up proper sewage and waste management systems will take time. Burying the dead, decontaminating water supplies, providing food and shelter and tending to the sick and injured are the initial focus of the recovery program. This in turn will slowly introduce order into a chaotic situation, but it will take months or years to remedy.

© Dr. Barry Dworkin 2005

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Originally published in The Ottawa Citizen September 20, 2004
Original Title: The Testes of Time

Young men rarely see their family doctor (if they have one). There is a tendency to think that nothing can really go wrong in your late teens or 20s.

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Originally published in The Ottawa Citizen August 17, 2004
Original Title: The thin white line

CREDIT: Wayne Cuddington, The Ottawa Citizen X-rays, although the first test to be done, may not show a stress fracture. An MRI is better for diagnosis.

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The pressure and stress exerted upon the feet and lower extremities can be substantial. A common class of sports-related injury is stress fractures.

Stress fractures can be difficult to diagnose because they may not be seen on an X-ray immediately after an injury.

It should be suspected when the patient states that he or she can identify a specific region of bone pain. This is especially telling if there is a recent history of a new exercise routine or program, or an increase in exercise intensity or level.

Track and field sports account for more than 50 per cent of the stress fractures in men and 64 per cent in women. Platform diving and rowing, although not considered high-impact sports, may lead to stress fractures especially in the metatarsal bones of the feet (the bones that connect the foot to the toes) and the ribs. Softball, hockey, swimming and golf are not likely to cause fractures.

Although upper extremity and rib stress fractures do occur, they are much less common than the lower extremity stress fractures. The focus for this column will be on bones of the lower leg (tibia and fibula) and the feet.

The bones most likely to be affected are the tibia (shin bone) and the metatarsals. Fractures of the pelvis, femur (thigh bone), fibula (bone running parallel to the tibia in the lower leg) and some other bones of the foot occur less commonly.

The fracture is due to the repetitive injury of the bone usually from the pounding nature of the activity. This causes microfractures to form.

The injured or microfractured bone tries to repair itself. However, if the same activity continues, the microfractures coalesce into a stress fracture. It is like chipping a block of ice. Small cracks appear each time. Eventually, with enough chips, the ice will crack. The bone cannot keep up with repairing the damage and eventually cracks from the strain.

Although athletes do suffer from these fractures, non-athletes or deconditioned people beginning a new exercise program are at high risk for injury. Women are more likely than men to develop fractures. Sixty per cent of people who suffered from a stress fracture will develop another when they resume the same exercise regimen.

Half of all stress fractures in children and adults occur in the tibia, usually because of excessive running or jumping. Metatarsal fractures account for another 25 per cent of stress fractures and commonly affect the second and third metatarsal bones near the toes.

Other areas affected to a lesser extent are the fibula and a bone in the midfoot called the navicular bone.

Endurance athletes can develop fractures of the femur. They are rare but they have a high incidence of not healing.

Signs and symptoms that aid in the diagnosis of stress fractures include a dull ache or pain localized to a specific site in the lower extremity that worsens with weight bearing or exercise. The area may be swollen but the tell-all sign is pain with direct palpation.

A fracture of the femur can present as pain in the groin, front of the thigh or knee. The hip is painful to move.

X-rays, although the first test to be done, may not show the fracture; it may never appear on the X-ray, or it can take from two to 10 weeks before it can be seen.

A nuclear bone scan is able to detect early stages of stress fractures. MRI is better than regular X-ray tests for diagnosis and can outline the fracture better than a bone scan.

Nonsurgical interventions for the treatment of stress fractures include using ice, nonsteroidal anti-inflammatory drugs (NSAIDs) and resting the bone for several weeks or until the pain resolves. Warm-ups and stretching prior to resumption of activity is recommended. The exercise regimen should be gradually increased to avoid a new fracture.

Injury prevention includes pre-exercise stretching with a warm-up. This is especially important for tibial stress fractures. Light footwear and a smooth soft running surface such as a dirt path or grass will also reduce the fracture risk.

Some injuries may require casting or a special orthotic shoe. There is some evidence that using an aircast helps the athlete return to the activity sooner. Certain types of femoral fractures may require surgical repair. Each bone type has its own set of treatments and is best discussed with your doctor.

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Originally published in The Ottawa Citizen May 18, 2004
Original Title: I’ve got blistahs on my fingahs

What are the common hand infections? What causes them and how are they treated?

Although by no means a comprehensive guide, there are five common infections encountered in the emergency room or your family doctor’s office.

The anatomy of the hand has many enclosed small spaces, each segregated from the other. This compartmentalization can foster local infections leading to significant damage within hours.

The location of the infection, underlying medical condition (e.g. diabetes, sexually transmitted disease or immune system deficiencies), intravenous drug use, tropical fish aquarium exposure, and type of injury (abrasion, laceration, burn, bite, crush or penetration) will dictate the approach to wound and infection care.

The basic approach for successful outcomes includes early splinting of the affected area, elevation of the hand above heart level, antibiotics and incision and drainage of abscesses, if present. Splinting and elevation can ease the pain and swelling and protect the infected area. A tetanus shot is usually required.

Your physician or nurse will irrigate and cleanse the wound if it is split open. Any dead or dying tissue will be removed (debrided) because it can promote infection.

A paronychia occurs when the top layer of skin bordering the fingernails is traumatized via a manicure, dishwashing, an ingrown nail, hangnail or thumb sucking in children.

It can cause localized redness, pain and swelling. If left untreated, an abscess can form that may drain pus from the wound’s edge.

An early measure to help prevent the infection’s progress is 20-minute hot water soaks three to four times a day for two to three days. Usually the water temperature should be equal to the individual’s maximum bearable range. The hot water creates a local temperature environment that is inhospitable to bacteria. Application of topical antibiotics like mupiricin (Bactroban) or fusidic acid (Fucidin) can help destroy the remaining bacteria. These two measures are sometimes all that is required to cure this infection.

Abscesses must be incised and drained. Severe paronychias may require an oral antibiotic.

Abscesses that form in the pad of the fingertip are called felons and commonly affect the thumb and index finger. It is caused by penetrating trauma from splinters, glass, abrasions and minor puncture wounds. The pain is severe and throbbing; much worse than a paronychia.

Sometimes if caught early, hot water soaks, elevation and oral antibiotics may obviate the need for a surgical approach.

The markedly painful abscess will fill up the space within the finger tip and will require incision and drainage. Tissue death will result if not treated promptly. Osteomyelitis or bone infection, a significant complication of felons, can take weeks to months of antibiotic therapy to eradicate.

The herpes simplex virus can cause infections of the finger called herpetic whitlow. If it infects the fingertip, it may be mistaken for a felon. The affected finger will suddenly swell, turn red and become painful. Small tiny vesicles may initially appear on the skin, then coalesce into a larger infected area. Some people may have a fever and swollen lymph nodes in the armpit and elbow.

Prompt treatment with antiviral medications like acyclovir, valacyclovir or famciclovir may reduce the infection’s severity, but is not a cure. The disease is self-limited and resolves after 14 days. It is infectious and affected people should avoid direct contact with others. The wound should be covered to reduce spread.

Herpetic whitlow can recur in 30 to 50 per cent of cases but the initial infection is usually the most severe.

Puncture wounds to the palm of the hand and fingers can introduce bacteria into the sheath of tissue that surrounds and coats the tendons. These tendons are responsible for finger flexion. Pyogenic flexor tenosynovitis is a surgical emergency. It usually requires surgical intervention and intravenous antibiotics within 12 to 24 hours after the initial infection.

Fist-fights cause injuries to the back of the hand. Commonly lacerations or punctures occur from someone’s tooth. The wounds usually lie over the knuckle. These clenched-fist injuries can quickly cause considerable damage and infection to the tendon that extends the fingers, the joint and bone. These wounds are considered to be contaminated requiring prompt surgical intervention.

The wound has to be surgically explored, irrigated and cleaned and treated with antibiotics.

It is easy to be fooled by penetrating trauma. The hand has small spaces or compartments that, if infected, can rapidly develop into serious complicated trauma leading to a permanent loss of function. Prompt evaluation by a physician is crucial. Do not delay even if the injury does not look serious. It usually is.

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Originally published in The Ottawa Citizen February 12, 2004
Original Title: A Burning Issue

Many people are unaware of the proper management of burns. Is there a need to apply creams, antibiotics, salves or natural products to promote healing? What are the first steps to prevent or minimize skin damage in the immediate aftermath of a burn?

An understanding of burns begins with a review of the four layers of the skin: the epidermis, dermis, subcutaneous (tissue under the dermis), and muscle.

The epidermis is the tough skin surface and our protective barrier against disease and the elements. The dermis resides under the epidermis and holds the small arteries, veins, sweat glands and hair follicles. The subcutaneous layer contains fat and more blood vessels. The muscle is the deepest layer.

Immediate treatment of mild to moderate burns is vital to lessen the damage. The treatment of severe burns is beyond the scope of this column.

Burn severity and its potential complications relies on the depth of skin damage, the percentage of burned body surface area, the burn mechanism (e.g. hot sticky tar versus a flash flame) and the area affected (face, hands, eyes, genitals, etc). In addition to fire and heat, radiation, electricity, chemicals and sunlight are other causes of burns.

Thin or superficial burns (first-degree burns) are red and painful. The skin may be slightly swollen and turns white (blanches) if you press on it. Damage is limited to the epidermal layer and the skin may peel away a few days after the burn. It usually heals within three to six days.

Second-degree burns cause blisters and are painful. There are two subcategories: superficial partial-thickness and deep partial-thickness burns. Superficial partial-thickness burns extend into the dermis. These blistering wet-looking wounds will seep fluid and blanch with pressure. They heal within three weeks.

Deep partial-thickness burns will extend into the subcutaneous fatty layer. These burns have a waxy appearance and do not blanch with pressure. Blisters will easily rupture if touched. Healing time is greater than three weeks.

Full-thickness third-degree burns cause damage to all the layers of the skin. The burned skin looks waxy white, charred or leathery gray in color. These burns may cause little or no pain if the nerves are damaged. These burns will only heal at the skin edges and form scars unless skin grafting is done.

Each of these burns requires specific treatment. Never apply butter, oil, ice or ice water on burns because it can cause more damage. It is best not to apply any lotions or creams until a burn-type diagnosis is made.

Superficial burns require immediate soaking in cool water (50 degrees to 55 degreesF or 10 degrees to 13 degreesC) for at least 10 to 15 minutes. The cool water will prevent some of the burned tissue from dying and help ease the pain. Although application of antibiotic creams and salves like aloe vera will not speed healing, they may provide some wound comfort. Use a dry gauze bandage to cover the burn if it needs protection. Acetaminophen or ibuprofen can help control the pain.

Superficial partial-thickness or deep partial-thickness burns should soak in cool water for 15 to 20 minutes. If the burn is small, apply a cool wet clean cloth to it for a few minutes each day. Thereafter, apply the antibiotic cream or ointment prescribed by your doctor. Wash your hands with soap and water and/or use an alcohol gel disinfectant before any dressing change.

Cover the burn with a nonstick bandage like Telfa and hold it in place with gauze or tape. Never use mesh gauze to cover the wound because it will incorporate itself into the tissue and is very painful and damaging when removed. Make sure you are up-to-date on tetanus shots. Stronger prescription pain-relieving medication is available.

Do not break any blisters because this can lead to infection. Your doctor may have to drain the blisters that cover joint areas because they may restrict movement.

Infected burns usually become increasingly red, swollen and painful and form pus. Look for these signs when doing a daily dressing change and consult your doctor should this occur.

Ensure your fingernails are cut short because burns itch as they heal. The damaged skin is sensitive to sunlight for up to a year after the injury. Exposure to sunlight can cause a permanent dark tanned patch.

If any of these burns covers an area greater than 10 per cent of the total body surface or is on the face, hands, feet or genitals, see a doctor immediately.

Full-thickness burns require immediate hospitalization. Do not remove any clothing stuck to the burn and do not soak the burn in water. Remove loose clothing and jewelry.

Electrical burns may not show any skin damage but often cause serious internal injuries. Chemical burns should be washed with copious amounts of water. Remove any chemical-soaked clothing. Do not apply anything to the burn because of the risk of a chemical reaction. Both chemical and electrical burns require an emergency room evaluation.

Prompt treatment of burns can help reduce the extent of scarring and infection.

For more information, check the website http://www.findarticles.com/cf_dls/m3225/9_62/67051929/p1/article.jh tml

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Originally published in The Ottawa Citizen October 2 , 2003
Original Title: Bending over backwards to save your back

About 90 per cent of adults will experience acute back strain and pain in their lifetime. It is a leading cause of work absenteeism and reduced productivity in Canada and the United States. Interestingly, most back pain resolves regardless of the type of therapy used. Indeed, most will return to work within three months of the injury. The problem is some will continue to experience recurrent back strain and movement limitations.

Back strain does not necessarily come from excessive weight bearing, carrying heavy loads, falls or trauma. Many times it is the accumulation of physical stress and strain and improper back support over time.

Factors that contribute to back strain include the ergonomics of a workstation, the type of shoes one wears, the type of chair, foot rests, car and truck back supports and medical illness among others.

Most often back strain is due to small tears in the lower back muscles responsible for maintaining posture. Some other causes include herniated or ruptured vertebral discs and arthritis.

Without proper back support, the back muscles can stiffen and become susceptible to strain. Sitting or standing for long periods can also lead to low back strain. Add in lifting and moving of heavy objects or physical labour and the risk of back trauma increases.

There are some common principles to prevent back injury. Even for those with a healthy back these principles will prevent potential back strain over the long-term.

Physical exercise, walking, cycling, swimming and other activities, will help maintain muscle tone and strength. Losing weight will reduce the strain on the lower back as it tries to maintain your body’s upright posture. Modified sit-ups (crunches) will reduce the curve in your lower back, strengthening the abdominal muscles that support it and reducing the chance of injury.

People who have physically demanding jobs are “industrial athletes.” Many succumb to injury because they do not warm-up before work by stretching and participating in conditioning exercises.

Choosing the proper back support techniques depends upon the type of physical activity and the work environment.

Many people remain seated at their desk for hours. The weight of the legs pulls the hips forward and increases the curvature (lordosis) of the lower back. You can feel the strain and tenseness in these muscles.

Shifting or rocking your hips side to side while seated can relax the pelvic muscles. Placing both feet on a footstool pushes and supports the lower back against the lumbar support of the chair. Standing up to move about every 30 to 60 minutes will loosen-up the back and legs.

Footstools can also make a difference when standing in one spot for prolonged periods. Placing one foot on a footstool or a phonebook reduces the curvature of the lower back alleviating muscle and spinal tension.

Feet can take a pounding over the course of a work day in the concrete-floored big box stores contributing to achy joints and back. Orthotics or cushion shoe inserts can act as a barrier to the unforgiving nature of concrete.

Sleep position plays a pivotal role in prevention. Placing one to two pillows under your knees while sleeping on your back will flatten your lower back against the mattress for better support. Similarly, when lying on your side, place a thick pillow between your upper thighs to prevent tilting of the pelvis. Lying on the stomach will increase the curvature of the lower spine and thus strain.

There are several common work-related injuries. Many people injure themselves by using one hand to quickly grab or lift an object. This sudden strain or stretch is akin to rapidly pulling on an elastic band. This rapid change exceeds the elastic’s ability to stretch and it snaps. Muscles respond in a similar vein. Slow deliberate movements instead of sudden jerky ones will prevent small tears within the muscle.

Lifting heavy objects from ground level requires a methodical and slow approach. Bend the knees and keep the back straight when lifting an object. Hold heavy objects close to the chest and slowly lift yourself up using your legs. Your lower back should not be bent at the waist in an attempt to pick up the object. Similarly avoid overstretching or straining to reach objects high up on a shelf.

Carrying infants and young children against the side of the hip can cause back injury should the child suddenly move. Back or front child carriers provide greater stability.

The cardinal rule for back care is to respect pain. If the back hurts, it is best to curtail the activity. For more information on back care: http://www.spine-health.com/, ,

© Dr. Barry Dworkin 2003

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Originally published in The Ottawa Citizen August 5, 2003
Original Title: BPH, PRCa, PSA:What’s the deal?

CJOH anchor Max Keeping’s selfless revelation about his prostate cancer has renewed interest in prostate disease and PSA testing. His announcement came the day after a group called Early Prostate Cancer Diagnosis launched a campaign geared at getting OHIP to pay for an the early screening called the prostate-specific antigen (PSA) blood test for all men over 40.

As it stands, the province will fund PSA tests for men who have already been diagnosed with prostate cancer and those who already have symptoms.

But diagnosing prostate cancer is sometimes no simple matter, even with the PSA test. Is it worthwhile to find the $25 in your own pocket for the peace of mind?

One thing that make prostate cancer hard to diagnose is that it has symptoms similar to those of other conditions, including benign prostatic hypertrophy (BPH), which usually starts after the age of 50.

This enlargement of the prostate gland can cause significant discomfort and potential bladder damage. The prostate increases in size in eight per cent of men aged 31 to 40, in 40 to 50 per cent of men aged 51 to 60, and over 80 per cent of men older than 80 years of age.

If you are a man and live to a ripe old age, chances are good you will get prostate cancer. You’re also very likely to survive it.

Autopsy studies show 10 per cent of men over 50 had prostate cancer, while 70 per cent of men over 80 had it. Ten per cent of prostate cancer is inherited. One in nine Canadian men will get prostate cancer and one in 29 will die of it.

The symptoms of BPH and prostate cancer slowly develop over years. The signs include getting up more frequently at night to urinate, needing to void after urinating, waiting longer for urinary flow to begin, dribbling after urination, urinating more often during the day and a slower, less forceful and sputtering urinary stream.

BPH and prostate cancer have the potential to obstruct the bladder’s efforts to empty. Urine accumulates and distends the bladder walls, which can permanently damage bladder function. It loses the ability to contract and expel the urine.

But other disorders can also be at fault, including a narrowing of the urethra (the tube running from the bladder to the tip of the penis) or the bladder outlet, bladder cancer, bladder stones, urinary tract and prostate infections, or poor nervous system control of the bladder.

A thorough medical history of urinary difficulties, nerve damage or disease, bloody urine, trauma to the urethra and medication use helps point the way to a specific diagnosis.

Rectal examinations will help assess prostate size and consistency among other characteristics and differentiate between benign versus malignant disease.

Several other tests will complement the evaluation, ranging from a simple urine test for blood and infection to more invasive procedures.

A common imaging test, a transrectal prostatic ultrasound, will determine the size of the gland, its consistency and if there are suspicious areas for prostate cancer.

Other tests will measure how well the bladder functions. If there is a clinical suspicion of prostate cancer, a prostate biopsy would be the next step.

BPH treatment involves lifelong medical therapy and, depending upon the clinical situation, surgery to remove part or all of the gland.

Prostate cancer treatment includes a combination of chemotherapy, surgery and radiation therapy. Early detection is essential.

There is contradictory and confusing information about the PSA test. Still, it remains a valuable tool especially for certain clinical conditions, race and age groups.

PSA is a protein produced by the prostate gland. Most of it is attached to other blood proteins, but some floats freely in the blood stream, not bound to other substances.

This unbound type, “free” PSA, is low in men with prostate cancer and high in men with BPH. The serum PSA test adds the bound and free PSA levels together.

PSA levels increase with gland enlargement. The test can be used as a cancer-screening tool for men between 50 and 69 years of age because of the predictable slow and steady growth of the gland and PSA values.

However, the PSA test has limitations, in part because of other influences on the prostate gland. Irritation, ejaculation, infection, obstruction of the urethra and direct pressure (from a rectal exam or anal intercourse) will pump more PSA into the bloodstream, artificially elevating the result.

Men over the age of 69 tend to have more rapid enlargement of the prostate and increasing PSA levels. The results must be interpreted according to age and race-based normal values. Failure to do so could lead to false positive or negative results.

The widely used cut-off serum PSA value of four nanograms per millilitre, an indicator for the suspicion of prostate cancer, remains controversial.

Recent evidence indicates lesser values being associated with cancer. In three studies of men aged 50 and older, 148 of 597 men without prostate cancer (25 per cent) had a PSA value of four or higher. And 136 of 319 men with prostate cancer (43 per cent) had values below four.

A “free” PSA test — a variant of the PSA test — might improve cancer-screening evaluation. This test measures the individual concentration of the total PSA and free PSA. The total PSA level must be more than four in order for this test, combined with the patient’s age, to differentiate BPH from prostate cancer.

To date, the evidence indicates a combination of digital rectal examination and serum PSA testing is the best available means to exclude prostate cancer. The recommendation is to start screening for prostate cancer by age 50 with a rectal exam and PSA.

Family history might result in earlier testing, say, at around age 40. Given the evidence that this is the best we have so far, it stands to reason to give men any opportunity to prevent the disease.

Every other test we have that is covered by OHIP has no age restriction. I do not think PSA should be subjected to this rule. The decision for the test is based on clinical interpretation of the facts and in the best interest of the patient. There must be consistency in the system.

Related articles:

1. American Cancer Society states prostate cancer screening test is of questionable value
2. PSA Screening Among Elderly Men With Limited Life Expectancies
3. The Sunnybrook Prostate Cancer Risk Calculator

Originally published in The Ottawa Citizen July 29, 2003
Original Title: The Stones Wrong Address Part III; Sand and water are more fun on the beach

Part 1
Part 2

During my residency at the Jewish General Hospital in Montreal, I watched a groaning patient in tremendous pain hobble into the emergency room, clutching his lower back and side.

The ER staff physician, his back to the ER entrance and writing his notes, said without the slightest hesitation: “Kidney stones. That groan is unmistakable.”

Passing a kidney stone ranks as one of the most painful events in a person’s life. Twelve per cent of white men and five per cent of white women will experience this by the time they’re 70.

Younger adults are more prone to stones than the elderly. Whites are more likely to develop stones than Asians and blacks. Kidney stones occur more frequently in hot, dry regions of the world.

Although many assume the kidneys are located in the lower back area, their true location is behind and below the rib cage in the middle back.

Millions of microscopic tubes within the kidney collect and filter blood and create urine. These tubes drain into larger collecting areas, the calyces, which lead to a large central region called the renal pelvis. Urine flows through from the renal pelvis into the ureter, the tube connecting the kidney to the bladder.

The anatomy of the kidney lends itself to the process of stone formation. Greater than normal concentrations of certain substances in the urine will crystallize and adhere to the collecting system of the kidney. These microcrystals gradually increase in size, forming stones ranging from the size of a grain of sand to as large as a golf ball.

Stone fragments can travel down the urinary system, either passing completely through or lodging within the ureter and obstructing the urinary flow.

Dietary habits pose a significant risk factor. Eighty per cent of stones contain calcium compounds, primarily calcium oxalate (and calcium phosphate to a lesser extent). Oxalate-containing foods include spinach, rhubarb, beets, strawberries, wheat bran, nuts and nut butters.

Bowel surgery, chronic diarrhea and short-bowel syndrome are among the medical conditions that increase the absorption of oxalate from the bowel. Dehydration will concentrate the urine, increasing the risk of stone formation.

Drinking a litre a week of soft drinks acidified with phosphoric acid can mildly increase the risk of stones.

Uric acid, a breakdown product of protein metabolism, is responsible for gout and can cause kidney stones. Eating red meat and drinking alcoholic beverages can increase blood uric acid levels.

Certain bacterial strains found in urinary tract infections can directly influence the production of struvite stones (magnesium ammonium phosphate).

People with high blood pressure have twice the risk of developing stones. There’s also a higher risk if you have a family member with a history of having stones. The chance of forming another stone after one year is 15 per cent, 35 to 40 per cent at five years and about 80 per cent at ten years.

The pain associated with renal colic, from hardly noticeable to excruciating, depends on how far the stone travels within the ureter. Spasms of severe pain can last 20 to 60 minutes. A stone found in the upper ureter/pelvis will cause flank pain in the area between the ribs and the hip. As the stone descends, the pain intensifies, radiating to the lower front part of the abdomen and groin.

Nausea and vomiting may accompany the attack. Some people may have painful urination and feel an urgent need to urinate. Blood in the urine is a common sign. Grains of sand or gravel may be present. Others may have less typical symptoms such as vague or sudden abdominal pain or penile or testicular pain.

Major complications include obstruction of the ureter and severe infections. The urine backflow due to complete obstruction can lead to damage of the delicate filtering structures within the kidney.

The diagnoses of a kidney stone are based on symptoms, urine tests, X-ray with special dye, ultrasound and CT scan imaging. Many people, unaware they have kidney stones, do not have symptoms. Discovering the stone commonly occurs when an X-ray or ultrasound of the abdomen is performed in the course of investigating a different medical condition.

For some, the treatment consists of pain control while waiting for the stone to come out. Stones greater than seven millimetres may need sound shock waves (extracorporeal shock wave lithotripsy) to shatter them into smaller pieces. Others may require a small fibre-optic tube with a snare at its end inserted through the urethra into the bladder and ureter to grab the stone.

People who have had one stone should increase their fluid intake to three litres per day. This will increase urine flow and help prevent the formation of microcrystals within the kidney.

Calcium restriction is not a requirement because oxalate is the main culprit. Restrict oxalate-containing foods instead. Avoid megadoses of vitamins C and D and reduce red meat if you have uric acid stones.

Related articles:

1. Citric acid in diet sodas may thwart kidney stone development
2. Chronic Kidney Disease Update
3. Travelling gallstones warrant emergency care