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Dangers of the flu, by Dr. Zach Levine

BT Montreal | posted Tuesday, Jan 16th, 2018

Flu —   caused by influenza virus

Virus shedding begins day before symptoms appear and lasts 5-7 days.  Most infective on 2nd and 3rd days after infection.  Correlated with fever.    (re shedding – shouldn’t go to work)

Every year 10-25% of canadians get flu and 500-1500 die from it

Virus lives longer with low humidity and lack of sunlight.  15 min on tissues, 5 min on skin, 1-2 days on plastic or metal.  Mucus protects (up to 17 days on banknotes!)

can include fever or feeling feverish/chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches and fatigue

Get the shot!  Safe for pregnant and breastfeeding women


See doc if sob, chest pain, drowsy, neck stiff, fever in infant less than 3 months, not urinating


Tamiflu/oseltamivir.  Best if given within 48hrs.  Lessens symptoms and shortens illness 1-2 days.  Can be used as prophylaxis if exposed.

Give to ppl with chronic dz (lung dz, cancer, liver dz, kidney dz, dm, smokers, 65+)


Remember you can infect others, even if you take meds and feel better

Prevention with hand washing, cough into bend of elbow


Flu shot (shot is dead virus, nasal is live weakened, only for ages 2-49):  everyone 6 months and older can get.  takes 2 weeks to gain immunity.  Can get if chicken egg allergy unless severe — if worried, 1/10th the dose and observe 30 min before giving the rest.

Some people get soreness, or mild flulike sx.

Caregivers should get it.

A typical cough shoots out jets of air several feet long, along with around 3,000 droplets of saliva at speeds of up to 50mph.

Sneezes typically contain as many as 40,000 droplets, some which leave the body at more than 100mph.

In moist air, these particles may remain relatively large, and drop to the floor. But in dry air, they break up into smaller pieces – eventually becoming so small that they can stay aloft for hours.  Moistness itself also hurts the virus.

The mask’s effectiveness is also heavily dependent on how the illness is transmitted. For airborne viruses and bugs expelled from the body in large droplets, the mask may be your best bet. The trouble is, the flu and other ailments aren’t only spread in this manner. One study found that 65 percent of viruses spread among flu patients consisted of small particles. Unfortunately, the generic face mask is not airtight and cannot offer protection against these smaller particles. That means that if a sick person sitting next to you coughs, you can catch their ailment regardless of if you’re wearing a mask or not.

The CDC wrote in its H1N1 flu advisory that “facemasks help stop droplets from being spread by the person wearing them. They also keep splashes or sprays from reaching the mouth and nose of the person wearing them. They are not designed to protect against breathing in the very small particle aerosols that may contain viruses.”

Also, the CDC reminds us that the flu’s most effective avenue of transmission is not the air but via direct contact with an infected individual. For example, drinking from a glass that was shared with a sick person, or touching your mouth after touching a surface also touched by a sick individual is not only more likely to get you infected but is something the mask offers absolutely no protection against.

Alcohol during the Holidays

BT Montreal | posted Monday, Dec 18th, 2017

By Dr. Zach Levine, ER physician, MUHC


Overview:  Alcohol is addictive and in excess is bad, dangerous, addictive, but

it gives a buzz, is enjoyable, is a disinhibitor,

That’s why we can’t get rid of it, prohibition in the US failed

Same in the many places where it is officially banned — Northern QC native communities, certain middle eastern nations where it is underground

Russia France Greece 🇬🇧 Germany USA etc all have alcoholism


Maybe for another time — Alcohol vs Pot


Is alcohol good for your health?

It’s a mixed bag but it’s not worth starting to drink to help one’s health.  Drinking too much alcohol contributes to accidents and injuries and can lead to liver disease, high blood pressure, various cancers, and birth defects, among other health problems. However, moderate alcohol use may provide certain health benefits, particularly with regard to coronary heart disease. Understanding the possible risks and benefits of alcohol is essential to make an informed decision about alcohol use.

HOW MUCH IS ONE DRINK? — Alcoholic drinks come in multiple forms and contain differing amounts of pure alcohol (ethanol). In the United States, one portion of alcohol is defined as approximately 10 to 15 grams of ethanol, which can be found in:

  • One 12 ounce bottle or can of beer (roughly equivalent to the 330 mL cans of beers sold in some countries)
  • One 5 ounce serving of wine (about 150 mL)
  • One shot (1.5 ounces) of 80-proof distilled spirits (about 50 mL)

Moderate drinking is generally defined as 3 to 9 servings of alcohol per week, depending on age, sex, and other conditions. For example, the National Institute on Alcohol Abuse and Alcoholism defines ‘low-risk’ drinking as no more than three drinks on any single day and no more than seven drinks per week for women, and no more than four drinks on any single day and no more than 14 drinks per week for a man.


Binge drinking is defined as a pattern of drinking that brings a person’s blood alcohol concentration (BAC) to 0.08 or above. This typically occurs when men consume 4 or more drinks or women consume 2.5 or more drinks in about a two-hour timeframe (varies a lot depending on size, tolerance)

It is most common in 18-34 year olds.  It is twice as common in men as in women.  Binge drinking is more common among people with household incomes of $75,000 or more than among people with lower incomes. However, people with lower incomes binge drink more often and consume more drinks when they do.

Binge drinking has been associated with unintentional harm and injuries from car accidents, falls, burns, and alcohol poisoning. Due to the altered state of mind, those who binge drink can fall victim to suicide, violence from their partner, and sexual assault.

Repeated binge drinking is associated with Chronic diseases such as high blood pressure, stroke, heart disease, and liver disease, cancer of the breast, mouth, throat, esophagus, liver, and colon, Memory and learning problems, and Alcohol dependence.


Legal limit: In Quebec and the rest of Canada, the maximum legal BAC for fully licensed drivers is 80 milligrams of alcohol in 100 millilitres of blood ( BAC/blood alcohol concentration of 0.08.  This is 17mmol/L in hospital units). Driving with BAC over 0.08 is a criminal offence.  This applies to everyone except drivers 21 or younger and professional drivers who are transporting other people (e.g. bus drivers, taxi drivers, etc.), in which case the limit is 0 mg (zero).


HEALTH CONDITIONS AND ALCOHOL — Multiple studies suggest that consuming alcohol can affect the risk of developing certain health conditions.

Cardiovascular disease — Cardiovascular disease, including disorders of the heart, blood vessels, and blood circulation, is the leading cause of death in North America. However, several studies suggest that moderate alcohol use, as compared to heavy drinking or abstaining, decreases the risk of coronary heart disease (CHD).

High blood pressure — People who consume more than two drinks per day have up to a twofold increase in the incidence of high blood pressure compared with nondrinkers. However, the effect of drinking less than two drinks per day on high blood pressure remains unclear.

Atrial fibrillation — Drinking several drinks at a single occasion, even among individuals who otherwise drink safely, can induce abnormal heart rhythms, including atrial fibrillation (aka “holiday heart”). There may be a slightly increased risk of atrial fibrillation (the most common chronic heart rhythm disturbance) among moderate drinkers, although it is still uncertain if this may result from occasional binges among otherwise moderate drinkers or occurs even within recommended limits of alcohol use.

Peripheral vascular disease — Peripheral vascular disease can cause pain in the calves with walking, also known as claudication. Moderate alcohol use reduces the risk of peripheral artery disease in healthy men.

Stroke — Alcohol consumption has been shown to affect the risk of stroke in contradictory ways, depending upon the amount of alcohol consumed and the type of stroke. A stroke occurs when brain tissue dies as a result of a sudden, severe disruption of blood flow and insufficient oxygen. Strokes may be due to a blockage (ischemic stroke) or rupture and leakage (hemorrhagic stroke) of one of the blood vessels supplying the brain.

Heavy alcohol use increases the risk of both ischemic and hemorrhagic stroke. Moderate alcohol use is associated with fewer ischemic strokes; the risk appears to be lowest in people who consume one drink or less per day. In contrast, the risk of hemorrhagic stroke appears to rise even with minimal alcohol use.

Breast cancer — There is consistent evidence that breast cancer risk is higher for women consuming moderate to high levels of alcohol (three or more drinks/day) compared with abstainers. Drinking as little as one to two drinks per day also appears to increase this risk

Taking folic acid (folate) may reduce the effect of alcohol consumption on breast cancer, suggesting that women who drink alcohol may benefit from a daily multivitamin fortified with folic acid.

Cancers of the head and neck and digestive tract — Alcohol use has been linked to several types of cancer of the head and neck and digestive (gastrointestinal) tract, even at low levels of consumption. People who drink and smoke have a greater risk than would be expected from either factor alone.

Cancer arising within liver cells (hepatocellular carcinoma) has been linked to alcohol use. This may be related to liver scarring (ie, cirrhosis) that occurs in people who consume excessive amounts of alcohol since cirrhosis is a major cause of hepatocellular carcinoma. Low levels of alcohol do not clearly cause cirrhosis.

However, even at low levels, drinking may increase the risk of hepatocellular cancer in people with inflammation of the liver (hepatitis) due to infection with certain viruses (ie, hepatitis C virus). People with chronic hepatitis should avoid alcohol.

Cirrhosis (scarring of the liver) — Low levels of alcohol do not clearly cause cirrhosis. Heavy drinking is generally required to cause cirrhosis in men in the absence of other factors.

Alcohol is the leading cause of chronic liver disease and failure in North America.

Gallstones — Moderate alcohol use has been shown to lower the risk of gallstones. However, heavy drinking may reverse this benefit.

Pancreatitis — Heavy drinking increases the risk of both sudden (acute) and long-term (chronic) inflammation of the pancreas (pancreatitis).

Osteoporosis — Heavy drinking increases the risk of hip fractures because it increases the risk of both osteoporosis and falls.

Pregnancy — There is a significant risk of birth defects related to use of alcohol use during pregnancy. Heavy drinking can cause fetal alcohol syndrome, which prevents normal growth, and may cause intellectual disability (mental retardation), malformations of the skull and face, and other findings (Fetal Alcohol Syndrome).

Moderate alcohol consumption may also be harmful, although this is a matter of some controversy. There is no known benefit of alcohol use during pregnancy. Thus, experts advise completely avoiding alcohol during pregnancy.

Perception of health and quality of life — Excessive and frequent alcohol use reduces quality of life for individuals, their families, and others around them, potentially leading to failure at work or school, interpersonal problems, and physically hazardous situations.

Accidents and trauma — Alcohol use increases the risks and severity of injury from motor vehicle accidents.

Exposure to alcohol is generally measured in blood alcohol concentration (BAC) rather than drinks per day or week. In most of the United States, the legal BAC limit for driving is 0.08 percent, which corresponds to about 4 drinks for a 200 pound man and 2.5 drinks for a 150 pound woman. However, the risk of having an accident while driving doubles at a BAC of only 0.05 percent, and driving ability is impaired with BACs as low as 0.02 percent.

Alcohol also increases the risk of injury from other sources. It has been shown to impair a pilot’s ability to fly and an operator’s ability to control a boat, bicycle, and snowmobile. In addition, occupational injuries, falls, drownings, burns, and hypothermia are more common in those who use alcohol, particularly in heavy drinkers.

Good resource — https://www.facs.org/~/media/files/quality%20programs/trauma/alcoholinjury.ashx

Violence — Alcohol is involved in more than one-quarter of all rapes, at least one-half of serious assaults, and one-half to two-thirds of all homicides.

Suicide — Alcohol abuse is associated with an increased risk of suicide. Although moderate drinking does not appear to raise suicide risk, episodes of heavy drinking cause disinhibition that can increase suicide risk.

IS ALCOHOL SAFE FOR ME? — The bottom line is that it is difficult to weigh the benefits and risks of alcohol. Nevertheless, several important conclusions can be drawn:

  • Beginning to drink alcohol may be inappropriate for people who have been lifelong abstainers. There is no evidence that lifelong abstainers who begin drinking in middle or older age will lower their risk of any disease.
  • The diseases that may be prevented by moderate drinking (eg, coronary heart disease and ischemic stroke) are most prevalent in older adults, men, and people with CHD risk factors (eg, hypertension, hypercholesterolemia, smoking, diabetes mellitus). For these groups, moderate alcohol use may reduce their risk of these conditions.
  • For young to middle-aged adults, particularly women, moderate alcohol use increases the risk of the most common causes of death, such as breast cancer and trauma. Men under age 45 years also may experience more harm than benefit from drinking. In these younger age groups, moderate alcohol use is unlikely to reduce the risk of dying.

Consuming less than one drink daily appears to be safe (that is, if not done before or while operating a car or heavy equipment), although even that level of drinking can be dangerous for some people (see next section).

Reasons to avoid alcohol — Alcohol use is not recommended for individuals who:

  • Are younger than the legal drinking age (18 in Quebec)
  • Are pregnant
  • Have a personal or strong family history of alcoholism
  • Have liver or pancreatic disease related to alcohol
  • Have precancerous conditions of the digestive tract
  • Operate potentially dangerous equipment or machinery (including cars, boats, planes, or construction equipment)

Wine versus other alcoholic beverages — Some research suggests that wine provides the strongest protection against cardiovascular disease, possibly due to naturally occurring compounds known as flavonoids. In France, for example, death from CHD is lower than would be expected from the high rate of smoking and saturated fats in the diet; this “French paradox” has been attributed to frequent red wine consumption.

However, other studies indicate that all alcoholic beverages offer cardioprotective benefits. Whether beverage type matters for specific diseases other than CHD remains uncertain, although most evidence suggests that it does not.

A safe dose of alcohol — As mentioned above, for some people, no amount of alcohol is considered safe.  However, for individuals without such conditions, the healthiest dose of alcohol appears to be in the range of 0.5 to 1 drink of alcohol daily.

Gender differences — Established recommendations for safe levels of drinking do not address an “ideal” level of alcohol consumption. However, they advise

  • No more than two drinks daily for men
  • No more than one drink daily for women

What is the best approach in my case? — The following guidelines may help in making an informed decision about alcohol use:

  • Consult a healthcare provider to determine the specific risks and benefits of alcohol use. Multiple factors must be considered in any such “risk-benefit analysis,” including age, sex, personal medical history, family history, diet, physical fitness, and certain lifestyle choices such as smoking, among others.
  • Women should not drink any alcohol during pregnancy; in addition, experts advise that women should stop drinking when trying to conceive.
  • Never consume alcohol before or while driving or operating any potentially dangerous equipment.


holiday heart syndrome was coined. It was defined as an acute cardiac rhythm and/or conduction disturbance, most commonly supraventricular tachyarrhythmia, associated with heavy ethanol consumption in a person without other clinical evidence of heart disease.


Blood alcohol concentration Clinical effects
20-50 mg/dL (4.4-11 mmol/L) Diminished fine motor coordination
50-100 mg/dL (11-22 mmol/L — 0.08 is 17mmol/L) Impaired judgement; impaired coordination
100-150 mg/dL (22-33 mmol/L) Difficulty with gait and balance
150-250 mg/dL (33-55 mmol/L) Lethargy; difficulty sitting upright without assistance
300 mg/dL (66 mmol/L) Coma in the non-habituated drinker
400 mg/dL (88 mmol/L) Respiratory depression


What is alcohol poisoning? — Alcohol poisoning is what happens if someone drinks far too much in a short amount of time. This is different from being drunk or having a little too much to drink. Alcohol poisoning is life-threatening. A person with alcohol poisoning could stop breathing or choke on his or her own vomit.

What are the symptoms of alcohol poisoning? — Some of the symptoms are the same as those for a person who is “just drunk.” For instance, people who have alcohol poisoning can seem confused or have trouble standing up. But some of the other symptoms of alcohol poisoning are more serious. Alcohol poisoning can slow or stop a person’s breathing. It can also cause seizures or an irregular heartbeat.

Call for an ambulance (in the US and Canada, dial 9-1-1) if the person:

  • Stops breathing or goes 10 seconds or more without breathing
  • Is breathing very slowly (fewer than 8 breaths in 1 minute)
  • Turns blue or very pale, and his or her skin feels cool to the touch
  • Has a seizure
  • Is passed out and cannot be woken up at all
  • Cannot stop vomiting
  • Looks very sick

What will the doctors at the hospital do? — If someone goes to the emergency room with alcohol poisoning, the doctors there can make sure that the person:

  • Keeps breathing. (If the person stops breathing, the doctors can put him or her on a breathing machine.)
  • Gets fluids through a tube in a vein (IV) if needed. (This can be important if the person has been vomiting a lot)
  • Is healthy except for the alcohol. People who have been drinking sometimes have other problems that are tough to spot, because they cannot tell you what they are feeling. For instance, people who have been drinking often fall down or otherwise hurt themselves. Doctors can use X-rays and other tools to spot possible injuries or other health problems.

Is there anything doctors can do to get the alcohol out of your system? — No. Alcohol is absorbed into the body very quickly. It does no good to empty the stomach. There is nothing that can soak up or cancel out the effects of the alcohol. The only thing that gets rid of alcohol in the body is time.

What can you do at home to help keep someone safe? — For people who have been drinking but do not seem to need emergency care, you can:

  • Keep checking their breathing and call for an ambulance (in the US and Canada, dial 9-1-1) if their breathing slows too much or stops
  • Lay them on their side, so that they do not choke on their own vomit if they throw up
  • Check them for bumps, bruises, bleeding, or any sign of injury
  • Make sure they stay warm (use blankets)

If someone you know drinks so much that you are afraid for his or her safety, that might be a sign of a drinking problem. When he or she recovers, it might be good to sit down and talk about what happened. Suggest speaking to a doctor, nurse, or mental health expert who can help diagnose and treat a drinking problem.


Stay safe:

Have a plan – designated driver, sober person, hydrate

Drink in Moderation

Eat food

If alcoholism in family history, be especially vigilant…

Good friends look after each other

Avoid dangerous situations, wild unsupervised parties

Avoid using “other” drugs

Alcohol is not an anti-depressant

Don’t drink and drive!  DUI’s are serious offenses, with very tough consequences


Alcohol vs marijuana — https://www.nytimes.com/2015/03/17/upshot/alcohol-or-marijuana-a-pediatrician-faces-the-question.html

Shingles: Symptoms, Causes, Treatments by Dr. Zach Levine

BT Montreal | posted Tuesday, Dec 5th, 2017

  1. What is shingles?


Shingles is a painful rash that is shaped like a band or a belt. Shingles can affect people of all ages, but it is most common in those older than 50. Another name for shingles is “herpes zoster.”


  1. What causes shingles?


Shingles is caused by the same virus that causes chickenpox. After someone has chickenpox, the virus sometimes hides out, “asleep” in the body. Years later, it can “wake up” and cause shingles. The first time a person is infected with that virus, he or she gets chickenpox, not shingles.


  1. Who gets shingles?


RISK OF SHINGLES — Up to 20 percent of people will develop shingles during their lifetime. The condition only occurs in people who have had chickenpox, although occasionally, chickenpox is mild enough that you may not be aware that you were infected in the past.

Age — Shingles can occur in individuals of all ages, but it is much more common in adults aged 50 years and older.

Immune status — Shingles can occur in healthy adults. However, some people are at a higher risk of developing shingles because of a weakened immune system. The immune system may be weakened by:

  • Certain cancers or other diseases that interfere with a normal immune response
  • Immune-suppressing medications used to treat certain conditions (eg, rheumatoid arthritis) or to prevent rejection after organ transplantation
  • Chemotherapy for cancer
  • Infection with the human immunodeficiency virus (HIV), the virus that causes AIDS


  1. Is shingles contagious?


Yes and no. It is not possible to “catch” shingles from someone who has the rash. But it is possible to “catch” the virus and then get sick with chickenpox. Shingles and chickenpox are caused by the same virus.


You probably will not catch the virus (or get chickenpox) if you:

  • Had chickenpox or shingles in the past
  • Had the chickenpox vaccine
  • Were born in north america before 1980 (most people born before 1980 have had chickenpox even if they don’t remember it)


  1. What are the symptoms of shingles?


At first, shingles causes weird sensations on your skin. You might feel itching, burning, pain, or tingling. Some people get a fever, feel sick, or get a headache. Within 1 to 2 days, a rash with blisters appears. Blisters most often appear in a band across the chest and back. They can show up on other parts of the body, too. The blisters cause pain that can be mild or severe.

Within 3 to 4 days, shingles blisters can become open sores or “ulcers”. These ulcers can get infected. Within 7 to 10 days, the rash should scab over. By then, most people are no longer contagious.


  1. Can shingles be serious?

Pain and seriousness get worse with increasing age.

Yes. Shingles can be serious, but that is rare. About 1 out of 10 people with shingles will get something called “postherpetic neuralgia,” or “PHN.” People with PHN keep feeling pain or discomfort even after their rash goes away. This pain can last for months or even years. It can be so bad that it makes it hard to sleep, causes weight loss, and leads to depression.

Shingles can also cause:

  • Skin infections
  • Eye problems (if the rash is near the eye)
  • Ear problems (if the rash is near the ear)
  • Dangerous infections in people who have other health problems


  1. Should I be treated?


Yes — for the virus and if needed for the pain


Treatment of shingles usually includes a combination of antiviral and pain-relieving medications. The affected areas should be kept clean and dry.

Antiviral medications — Antiviral medications stop the varicella zoster virus from multiplying, speed healing of skin lesions, and reduce the severity and duration of pain.

Antiviral treatment is recommended for EVERYONE with shingles, and is most effective when started within 72 hours after the shingles rash appears. After this time, antiviral medications may still be helpful if new blisters are appearing.

Three antiviral drugs are used to treat shingles: acyclovir (Zovirax®), famciclovir (Famvir®), and valacyclovir (Valtrex®). Acyclovir is the least expensive treatment but it must be taken more frequently than the other drugs.


Pain medications — The pain of shingles and postherpetic neuralgia can be severe, and prescription medications are frequently needed.


Treatment of postherpetic neuralgia — Treatment is available to reduce pain and maintain quality of life in people with postherpetic neuralgia. Treatment generally begins with a low-dose tricyclic antidepressant, and may also include narcotic medications and an anti-seizure medication.

Tricyclic antidepressants — Tricyclic antidepressants (TCAs) are commonly used to treat the pain of postherpetic neuralgia. The dose of TCAs is typically much lower than that used for treating depression. It is believed that these drugs reduce pain when used in low doses, but it is not clear how the drug works.

Anti-seizure medications — Medications that are traditionally used to prevent seizures, called anticonvulsants, can sometimes reduce the pain of postherpetic neuralgia. They may be used instead of or in addition to TCAs. Anticonvulsants commonly used for postherpetic neuralgia include gabapentin (Neurontin®) and pregabalin (Lyrica®).

Capsaicin — Capsaicin is a substance derived from chili peppers that can help to treat pain. Capsaicin cream (Zostrix®) may be recommended to treat postherpetic neuralgia. However, the side effects of the cream (including burning, stinging, and skin redness) are intolerable for up to one-third of patients.

Topical anesthetics — Lidocaine (Xylocaine) gel is a medicine that you can rub into your skin. A lidocaine patch (Lidoderm®) is also available, which you wear on your skin for 12 hours per day. It delivers a small amount of lidocaine to the most painful or itchy areas. However, the benefit of lidocaine is likely to be moderate at best.

Steroid injections — For people with postherpetic neuralgia who have severe pain despite using the above measures, an injection of steroids directly into the space around the spinal cord may be considered. Steroid injections are not used to treat facial pain.

In one study of patients with postherpetic neuralgia for at least one year, steroid injections led to good or excellent pain relief in about 90 percent of individuals [1].


  1. When can I return to work?  How long is it contagious? — contagious until all blisters are dry and crusted over

If you have shingles, you may wonder when it is safe to return to work. The answer depends upon where you work and where your blisters are located.

  • If the blisters are on your face, do not return to work until the area has crusted over, which generally takes seven to 10 days.
  • If the blisters are in an area that you can cover (eg, with a gauze bandage or clothing), you may return to work when you feel well.


  1. How can we prevent shingles?

Who can get the vaccine?


Vaccination — a vaccine is now available to reduce the chance of developing shingles. If you do develop shingles after receiving the vaccine, your infection may be less severe and you are less likely to develop postherpetic neuralgia

There are two vaccines that have been approved for adults over 50 years.

Drugs in everyday life By Dr. Zach Levine

BT Montreal | posted Wednesday, Nov 8th, 2017

Drug: a medicine or other substance which has a physiological effect when ingested or otherwise introduced into the body.


**A substance taken into the body by any form (orally, intravenously, transdermally, intramuscularly, intranasally…) that affects the way our body functions, the way we think, or the way we feel — ie medications, OTC, illegal drugs, drinks and foods



Illicit: forbidden by law, rules, or custom

Narcotic:a drug or other substance affecting mood or behavior and sold for nonmedical purposes, especially an illegal one

Illegal and controlled “recreational” drugs in Canada:


Cocaine (stimulant from coca plant)

LSD (hallucinogen, altered sensorium)

Opiates – Heroin (semisynthetic), Fentanyl (synthetic)

Ecstasy (MDMA) – a stimulant

Ketamine – trance-like state, analgesia, sedation

Methamphetamine – stimulant

Magic mushrooms – change mood and perception, cause hallucinations

GHB – sedative, colourless and odourless

Rohypnol (nitrazepam)


Performance Enhancing Drugs:  (some legal, some not)

Anabolic steroids to build muscle

Stimulants to enhance performance and alertness

Also, amphetamine and methylphenidate increase power output at constant levels of perceived exertion and delay the onset of fatigue


Sedatives (to steady nerves and hands (eg/ for archery) for performance (beta blockers for performance anxiety)

Blood doping – to increase O2 carrying capacity of blood, for endurance sports


People use recreational (as opposed to performance enhancing) drugs for reasons including to change the way they feel, for pleasure, to self-medicate, and for social reasons.


Legal substances people use to affect how they feel or act:


Alcohol — legal at age 18 in QC, Alberta, Manitoba, 19 in the rest of the provinces.  It is the most abused substance in Canada



Psychoactive prescription medications

— ritalin, adderall — stimulants for treating ADHD

–Sleeping pills

–Depression (SSRI’s)

–Anti-anxiety medications

–For performance anxiety (beta blockers)


Legal, OTC stimulants:





The point is not to suggest an equivalence between all drugs.  At some point most people use some substance to alter how they feel and some to enhance performance, even if at work or school.


Illicit drugs can be deadly, especially cocaine, fentanyl.  Part of what makes them deadly is the lack of oversight so they can be “laced.”


There are many important questions, such as whether it’s fair if only some people have access to performance enhancing substances, whether it would be safer if drugs were legalized and regulated.


But for a doctor the main concern is your health, so we need to know what you took (or think you took)

iPhone X kicks off a new generation at a hefty cost

Winston Sih | posted Tuesday, Oct 31st, 2017


  • All-new design is slick and seamless
  • Face ID doesn’t just work—it works well
  • TrueDepth camera makes way for interactive augmented reality


  • It’s expensive
  • No Home button means you have to learn a whole new set of gestures
  • You better put a case on it—or else

When Apple first announced the 10th-anniversary iPhone at their September event in Cupertino, Calif., analysts questioned the decision to stagger the launch of two premium smartphones—and whether a stray from their traditional annual launch strategy would do them more harm than good.

Many enthusiasts decided to wait and see how iPhone X stacked up to its recently-launched sibling. While lineups for iPhone 8 were shorter than previous releases, carriers are reporting record-breaking preorder demand for iPhone X. But is a smartphone really worth a whopping $1,300? We were among the first to put iPhone X through its paces.


Redesigned from the inside out

The first thing you notice when picking up iPhone X is the gorgeous design. Everything has been reimagined. From the edge-to-edge 5.8-inch Super Retina OLED display, to the glass front and back that Apple touts as the ‘most durable ever in a smartphone,’ the stunning curvature of the edges makes this design an engineering feat and resembles a piece of artwork.


image2iPhone X remains water- and dust-resistant, featuring speakers 35 per cent louder, and is compatible with Qi-enabled wireless chargers. The device will turn heads and start conversations—though you’re best to throw a case on it, especially if you’re prone to dropping things. You know who you are.

No more Home button

First the headphone jack, now the home button. They finally did it. iPhone X is the first iPhone to do away with the one button that does virtually everything. Instead, users will need to learn a new series of gestures in iOS 11—like swipe up to go to your home screen; double press on the side button to activate Apple Pay; and hold the side and volume button to power off.

There was a learning curve for the first while. You’ll be reaching for the Home button annoyed it’s no longer there, and then cycle through the gestures. You get used to it—and is the price you pay for an all-screen display.

If you’re the type who likes using your smartphone with one hand, the new gestures may complicate things.  There are more swipes from the top, bottom, and sides. Unless you have long thumbs, you may need two hands to perform certain actions.



Facial recognition is the new fingerprint scan

For those who have become accustomed to the fingerprint authentication (known as Touch ID), iPhone X introduces a new facial recognition technology. I was blown away by how quick it learns your face and how effortless it is to use.

Face ID uses a new, front-facing TrueDepth camera that maps over 30,000 invisible dots to your face. It is stored securely on your device and is accurate to 1 in 1,000,000 that a random person can unlock your device. It also adapts to changes in appearance like facial hair growth, and cosmetic makeup.

It is used to do everything from unlock your device, authenticate into apps, and pay for purchases through Apple Pay. And none of the information is uploaded to the cloud, similar to Touch ID.


Cameras and AR

Camera enthusiasts will see a step-up in quality through not one, but two 12-megapixel rear cameras with dual optical image stabilization. This includes an updated Quad-LED True Tone flash that lights images more evenly and gives you more vibrant and accurate colours.



The popular portrait mode that was once for the rear cameras on iPhone 7 Plus and iPhone 8 Plus is now coming to iPhone X’s front-facing camera—something that will delight selfie takers and up their social media game.

The same TrueDepth camera that maps your face for security also unlocks a whole new world through augmented reality technology. Apple continues to double down on AR as a future way of interacting with the real world, and apps including Snapchat and IKEA are making use of ARKit. New Animojis in iMessage enable users to have 10-second clips of emojis mimicking your expressions and facial movements captured. A lot of fun to use and without a doubt going to be popular with the tweens—that is, if they can afford one.

Is it worth it?

And for the age-old question… The phone is expensive. Over $1,000 expensive. iPhone X will run you $1,319 and $1,529 for the 64GB and 256GB variants, respectively. So is it worth throwing down a month’s mortgage payment on a smartphone that is made of all-glass? It depends on which features are important to you.

iPhone X is without a doubt one of the slickest devices I’ve seen in a long time. The build quality is unlike many other smartphones on the market today. The iPhone changed the smartphone industry and paved way for a lucrative app market. It is the combination of well-built hardware, easy-to-use software, and the potential of apps to personalize the mobile computing experience that put iPhone on the map a decade ago. And the tech giant is hoping to do that all over again.

As preorder sales have proven already, enthusiasts who want to be part of that experience will line up overnight or wait upwards of six weeks to get hold of a device. But for many others, iPhone 8—even iPhone 7—will suffice, especially if the Home button is still of great value. Though, iPhone 8 will still make a dent in your wallet at just under $1,000, off contract.

Apple hopes that choice and category redefinition will help boost sales, after the wait-and-see approach of iPhone 8 resulted in shorter lineups at retail stores.

Rogers Communications is the parent company of this website.

Shortness of Breath, by Dr. Zach Levine

BT Montreal | posted Tuesday, Oct 24th, 2017

Shortness of breath (aka dyspnea) is the feeling of not being able to get enough air.  It is very uncomfortable and quite common.  It results from the brain sensing that the tissues are not getting enough oxygen, or CO2 is too high.


Shortness of breath is one of the most common reasons people go to the ER (along with chest pain, injuries, abdominal pain, back pain, headache, and infections).  Almost everyone experiences it at some point in their life.


Dyspnea is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations[2] or light exertion.


In 85% of cases it is due to lung disease, heart disease, or psychological causes, specifically asthma, pneumonia, cardiac ischemia, interstitial lung disease, congestive heart failure, chronic obstructive pulmonary disease, or psychogenic causes,[2][3] such as panic disorder and anxiety.[4] Treatment typically depends on the underlying cause.[5]


Causes range from the benign to the life-threatening:


Lung and airway causes: pneumonia




Pneumothorax (punctured lung)

Airway blockage from mass or infection


Being physically deconditioned (in bad shape) and exerting yourself


Cardiac (heart) problems:

Heart failure causing fluid backup into the lungs

Inflammation or swelling on the pericardium (the lining around the heart)

Inflammation of the heart muscle


Circulatory problems heart and lungs):

Pulmonary embolus (blood clot in the lungs)



Blood problems:

Anemia (low oxygen delivery to tissues due to low levels of hemoglobin in



Hormone problems:


Adrenal Gland insufficiency


Nerve problems:

Amyotrophic Lateral sclerosis (Lou Gherig’s Disease)

Guillane Barre Syndrome

Myasthenia Gravis


Psychiatric Problems:

Panic Attack

Generalized Anxiety Disorder


With so many causes for shortness of breath, what is one to do when one feels short of breath?  The safest thing to do is, of course, to see a doctor.  In a very brief period of time the doctor can rule out almost all of the causes and narrow it down to a handful of possibilities.


When discussing your case with you, the doctor will ask you how long the symptom has been present, what makes it better or worse, and what other symptoms you are suffering from.  In addition the doctor will find out about your medical history, medications, and recent illnesses.  The doctor will certainly ask whether you smoke, the major cause of COPD (chronic lung disease) and lung cancer, and whether you have been exposed to things that are potentially harmful to the lungs, such as asbestos.


Then the doctor will examine you.  First he or she will check your vital signs — your heart rate, blood pressure, oxygenation, and temperature.  Then they will listen to your heart and lungs and possibly examine other parts of you, if needed.


Finally, testing may be necessary.  Tests may include x-ray or CT scan of the lungs, pulmonary function tests to see how well you are able to inhale and exhale, and blood tests, and possibly more specialized testing.


Once all of this is done the doctor can give you a clear diagnosis and treatment plan.  Once you have this you no longer dealing with the fear of the unknown.

Online Medical Searches By Dr Zach Levine, ER physician MUHC

BT Montreal | posted Tuesday, Oct 10th, 2017

Online Medical Searches

By Dr Zach Levine, ER physician MUHC

People search the web about health

In a pew study over one year:

59% of people looked up health info

35% used the internet to try and diagnose their ailment

When people look up their symptoms they get the correct diagnosis 34% of the time

Medical questions:

— Most common online general health questions

·         Is bronchitis contagious?

·         Is pneumonia contagious?

·         How much water should I drink?

·         How many calories should I eat?

·         What is lupus?

·         How far along am I?

·         When do you ovulate?

·         What is gluten?

·         How long does the flu last?

·         Men search about urinary and erectile issues

·         Questions about non-western medicine

— Most common online symptom questions (mayo precedings/13)


Gallbladder infection



Sinus Infection


Anxiety Attack

H. Pylori infection

Heat Stroke

Lactose intolerance

— Most commonly searched diseases





Yeast infection





Lyme disease


Why people actually present to to the doctor

1. Skin disorders, including cysts, acne and dermatitis.

2. Joint disorders, including osteoarthritis.

3. Back problems.

4. Cholesterol problems.

5. Upper respiratory conditions.

6. Anxiety, bipolar disorder and depression.

7. Chronic neurologic disorders.

8. High blood pressure.

9. Headaches and migraines.

10. Diabetes.


What actually kills people (biggest killers in Canada)


Heart disease


Chronic lung disease



Alzheimer’s disease

Influenza and pneumonia


Kidney disease


1. Why the differences between what people Google and what they ask their doctor?

Embarrassment, forget, don’t have doctor, and they try to get a diagnosis online.  Also, they ask what’s on their mind at the time.  More likely to look up calories, water intake online.

2. Why the difference between what people as their doctor and what the doctor addresses?

Doctors focus on the big killers, ie cardiovascular disease, cancer risk factors and screening.  Patients focus on what’s ailing them and what worries them

3. Men vs women internet health – women search more, more well-informed, search for their families.  Women are often the reason men finally come to get things checed out

4. Increasing mental health concerns — unclear if incidence is going up but people are more aware of it, and look it up online

5. Mind body health relationship, integrative health — people understand that the mind and body are intimately connected, and that mental health is important to physical health.  And people like non-medicinal and natural treatments (but make sure there’s evidence)

6. The main point — you are not alone.  Millions have already searched that.  You can and should talk to your doctor about it.


_Details below_______________________________________________________________________________

Not much relationship between the top killers and what people search.

People search what they really want to know and what scares but may be embarrassed or afraid to ask.  People aren’t that scared of the top killers but they want to feel better (mental health), they look how to treat themselves (hemorrhoids, yeast infections).  And some things may have subtle symptoms — eg/Lyme disease.

Categories of questions (gomerblog):

1.    Too embarrassed to ask doctor — gonorrhea from toilet seat, anal sex

2.    Worries — is this cancer?

3.    Google second opinion – weight loss without exercise or diet, avoiding flu without the shot, lyme disease

Increasing searches about mental health issues point to both increasing awareness and maybe incidence (conflicting studies).  There is still stigma so people should talk about it, and doctors should ask about it.

Doctors and patients agendas often aren’t the same — docs may focus on the cardiovascular killers while patients are worried about their health now.

Lupus is a chronic inflammatory disease that occurs when your body’s immune system attacks your own tissues and organs. Inflammation caused by lupus can affect many different body systems — including your joints, skin, kidneys, blood cells, brain, heart and lungs.

(incidence about 1/1000 people, more in women and people of colour)

Lyme disease – spread by tick bite

Stage 1 – circular rash (approximately 50% get it), flulike illness

Stage 2 – headaches, joint pains,

Stage 3 – problems with memory mood sleep, fatigue, arthritis

Increasing in QC — 32 cases in 2011, about 200 this year (esp in eastern townships and monteregie, southwest of montreal – not many deer on the island of Montreal

Gender differences men v women internet health searches.  2015 study by Bidmon or Terlutter


Women were more engaged in using the Internet for health-related information searching. Women used the Internet for health-related information searches to a higher degree for social motives and enjoyment and they judged the usability of the Internet medium and of the information gained by health information searches higher than men did. Women had a more positive attitude toward Web 2.0 than men did, but perceived themselves as less digitally competent. Women had a higher health and nutrition awareness and a greater reluctance to make use of medical support, as well as a higher personal disposition of being well-informed as a patient. Men may be more open toward the virtual patient-physician relationship.


Women have a stronger social motive for and experience greater enjoyment in health-related information searches, explained by social role interpretations, suggesting these needs should be met when offering health-related information on the Internet. This may be interesting for governmental bodies as well as for the insurance and the pharmaceutical industries. Furthermore, women may be more easily convinced by health awareness campaigns and are, therefore, the primary target group for them. Men are more open to engaging in a virtual relationship with the GP; therefore, they could be the primary target group for additional online services offered by GPs. There were several areas for GPs to reinforce the virtual patient-physician relationship: the fixing of personal appointments, referral to other doctors, writing prescriptions, and discussions of normal test results and doctor’s notes/certificates of health.

Mind and body are intimately intertwined

Integrative medicine (UCI new $200B grant) – uses both western and complementary tx

Complementary – in addition to western

Alternative – instead of western

complementary/alternative tx — natural products, yoga, chiropractic and osteopathic manipulation, meditation, and massage therapy, acupuncture, hypnotherapy, homeopathy, naturopathy

Concussion and CTE by Dr. Zach

BT Montreal | posted Wednesday, Sep 27th, 2017

By Dr Zach Levine, ER physician MUHC


Background – Aaron Hernandez found to have grade 3 (of 4) CTE at the age of 27

Numerous other players have had CTE (bob probert hockey, junior seau football)


Sports with head contact — hockey, soccer, football, basketball (can have collisions), cycling (falls)

Sports are good for fun, relaxation, health, fitness, sense of achievement


ER visits for concussions have increased 60% over the past 10 years



What is CTE?

(used to be called demetia pugilistica or punch drunk syndrome, discovered in boxers)

Chornic traumatic encephalopathy.

Symptoms — memory loss, confusion, aggression, suicidality.

  • Difficulty thinking (cognitive impairment)
  • Impulsive behavior.
  • Depression or apathy.
  • Short-term memory loss.
  • Difficulty planning and carrying out tasks (executive function)
  • Emotional instability.
  • Substance abuse.
  • Suicidal thoughts or behavior.

So mood changes, thinking problems, memory loss


Diagnosed only on autopsy.  Buildup of tau protein in brain.

Caused by recurrent hits to head, symptomatic and not

Onset in the 40’s (much earlier than dementia, which has similar symptoms)


What is concussion?

Blow to the head that causes symptoms.  Not need to have LOC.

Concussion symptoms:

blurred/double vision



Sleep probs


Memory problems

Difficulty concentrating

Somatic (h/a), cognitive, and emotional symptoms


Get off the field.  Evaluation with SCAT5.

Rest 24-48 hours.  Then gradual activity, mental then physical, below symptom threshold


What is the relationship between CTE and Concussion?  Recurrent hits to the head cause CTE.  Not necessarily concusions.  Also not all people with multiple head hits or concussions will get CTE


The earlier one starts to get head injuries, the worse the outcome


Kids concussions and QC contact sport:


Kids concussions — big head thin skull, weak neck muscles, poor technique (use forehead where skull is thickest) all contribute.  Also less myelinated (and protected) nerve cells.


Girls get concussed as much if not more than boys (but less play football)


Takes longer to heal with subsequent concussions


NFL players have significantly higher risk of Alzheimer’s, ALS


Contact in sports in QC:

In QC hockey hitting starts at bantam (age 13-15) double letters


Football always has contact


The U.S. Soccer Federation has banned heading the ball in youth soccer for players under 10 years of age after a class action lawsuit revolving around concussions.

The federation also restricted heading the ball for players aged 11–13; they are allowed to head in practice sessions, but not in games.

The Canadian Paediatric Society has warned against heading in youth games


Helmets:  Helmets are good at preventing skull fractures, which is what they were made to do.


Risk factors for concussion:


Learning disabilities

Attention disorder

Migraine headache


What do you recommend for kids who play sports?


Consider having kids with risk factors not play contact sports

General Recommendations:

(Dr. Robert Cantu, sports med expert)

No contact sports until 14

No heading in soccer until 14

No head first sliding in bball


Need to teach proper body checking, heading technique in soccer, tackling in football


Individualize decision on contact sports — which sport, has child had prev concussions


Credit to Dr. Scott Delaney, top Quebec sport-related brain injury expert

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