Are you looking for the latests information on Palliative care, burnout, intimacy at the end of life? Well the most recent Palliative Care Conference provided just that and more. To listen to the talks and watch the slides (as if you were there!) simply follow the link for everything you might want to know.
What's going on in the clinic this week...
So, sometimes you just do not want to read a long winded blog post. I understand, there are times that I do not want to read a long blog post either. However, there is a young physician Nicholas Cohen, MD at Case Western Reserve doing his training in Family Medicine and he has been producing a video a week on family medicine topics for the last year. They are very good and very educational. SO, take a moment and look them over and see what you think!
I will be back to regular blogging in the next week or so after a much needed break.
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.
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.
- 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.
- 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.
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.
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.
One 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.
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