July 23rd, 2009 by Olajide Williams, M.D. in Health Policy, True Stories
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Stroke is the leading cause of adult disability in the United States and the third leading cause of death. Worldwide, stroke is the second leading cause of death. Like heart disease and cancer, serious stroke disparities persist in America. African Americans have a relative risk of stroke death that is 4 times higher that whites at ages 35-54, 3 times higher at ages 55-64, and 2 times higher at ages 65-74.
The reasons for this are the focus of my two blog posts.
Over the last decade, most of the research dollars spent on stroke has focused on treatment and recovery. Researchers have spent millions trying to come up with new blockbuster treatments that reduce stroke burden or reverse it’s disabling impact. Therapeutic clot-busters have emerged with narrow time-windows within which they must be administered. Relaxing these time constraints have been the subject of even more research, and stroke recovery laboratories explore brain re-learning, neuronal plasticity, and cellular regeneration.
While I believe that we must continue to remain leaders of new and innovative treatments of disease, there is no doubt in my mind that the best return for our healthcare dollars is prevention. It is the only thing that can reign in the runaway disparities in healthcare and reduce the physical and economic burden of disease among all Americans.
But prevention is complex. It is much more challenging than administering a clot-buster or taking a cholesterol-lowering drug. Prevention involves the entire community – the whole ecosystem. It involves the child or individual, his parents and grandparents, his schoolteachers, his neighborhood stores and local parks, his local government policies, his primary care physician, his local community clinic or hospital, his employment status, his wallet, and lastly, his genes. Compare this to treatment, which involves having access to particular medical interventions such as a drug or surgical procedure.
Stroke prevention can be subdivided into primordial prevention (preventing stroke risk factors like high blood pressure, diabetes, and obesity, from developing in the first place through healthy living), primary prevention (preventing a first stroke by treating identified modifiable risk factors like high blood pressure etc), and secondary prevention (preventing a second stroke from occurring by controlling risk factors and administering specific treatments like taking a daily aspirin or having surgery to open up clogged arteries in the neck).
For the purposes of this post, I will focus on primordial prevention. To begin, I will re-introduce the root causes of disparities outlined previously:
- Educational status
- Employment status
- Insurance status
- Income level
How do these factors influence primordial prevention? How do they interact to define ecological conditions within a specific community? How did they contribute to the young boy’s adolescent stroke? To begin, I will list factors endemic to the young boy’s environment:
1] Low Health Literacy – the “hidden dragon” of all treatable risk factors; so often underestimated and so dangerous to the beholder.
2] Unacceptable numbers of uninsured – the “crouching tiger” threatening to tear down the entire health system
3] Poor access to care – an unforgiving predicament.
4] Limited access to healthy and inexpensive food
5] Ubiquitous access to unhealthy and cheap food
6] Low levels of non-occupational physical activity or leisure-related exercise
7] High tobacco and alcohol consumption.
8] Chronic persistent stress levels that overwhelm coping mechanisms.
In a study by Mauricio Avendano and Maria Glymour, wealth and income levels were shown to be independent risk factors for stroke. Another study by Glymour, Avendano, Haas, and Berkman showed that childhood social conditions (southern state of birth, parental Socio-Economic Status or SES, self-reported fair/poor childhood health, and attained height) predicted stroke risk in black and white adults. Moreover, adjustment for adult SES, in particular wealth, nearly eliminated all the disparity in stroke risk between black and white subjects
The ecological conditions that shaped the young boy’s physical and limbic traits are examples of an uneven playing field. He was born into it – just like I was born into my little world. The sporadic binging on cheap ubiquitous fast food whenever his mom had a little money and the absence of playtime ultimately led to his childhood obesity. The complex conditioning of his limbic needs led to a psychological fragility that was encased by a shell of defensive behavior that in-turn caused truancy. Substance abuse was around the corner waiting patiently for him. By age 15, the young boy was already a user; with open arms he was welcomed into “the hustle”. Mom was broken. One could see it in her eyes. She no longer worked. She no longer cared. That is, until her son had a stroke when he was just 17-years-old – the day the drought ended, and she cried.
It was a hemorrhagic stroke. The high blood pressure in his brain arteries caused by accelerated atherosclerosis – the consequence of his substance abuse (tobacco, alcohol, cocaine), type-two diabetes, and undiagnosed hypertension – was what caused the stroke. The stroke was so large that it shifted half of his brain across the midline of his skull, crushing it against the inner-table on the other side. Fortunately (some would say), the kid survived. Unfortunately, he wanted to die – 17-years-old and nursing home bound, unable to speak or swallow or move his right side.
The stroke was the final blow dealt by a cascade of disparities all too common in America.
June 4th, 2009 by RamonaBatesMD in Better Health Network
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My mother died last Tuesday. She had her coronary bypass surgery just one week before that day. It was during her CABG that she had her strokes. Yes, strokes, plural. She was one of those 1.5% who suffer macroemboli cerebral strokes during coronary bypass surgery.
I went looking for information on it earlier this week. I went through my training without ever seeing this complication. Like everyone, I never thought my family would be the one. I think it is better to go to surgery, NOT thinking you will be the “statistic” as far as complications go. Anyone having surgery, SHOULD go into it feeling hopeful and thinking everything will go perfectly.
The article referenced below is a good review of this complication – stroke during coronary bypass surgery. The study is a retrospective review of 6682 consecutive coronary bypass patients who only had the CABG procedure and not other simultaneous procedures, such as carotid endarterectomy.
They list the possible sources of the emboli as the ascending aorta, carotid arteries, intracerebral arteries, or intracardiac cavities. They state that they believe the most likely source is the ascending aorta, for the following reasons:
First, the ascending aorta is the site of surgical manipulations during CABG, whereas mechanical contact is not made with the other potential sources of emboli. Embolization of atherosclerotic debris is most likely to occur during aortic cannulation/decannulation, cross-clamp application/removal, and construction of proximal anastomoses. However, embolization of atherosclerotic debris may also occur when the aorta is not being surgically manipulated, due to the ‘sandblast’ effect of CPB.
Second, the majority of our independent predictors of stroke – elderly age, left ventricular dysfunction, previous stroke/TIA, diabetes, and peripheral vascular disease – are strongly associated with atherosclerosis of the ascending aorta.
Third, our chart review suggested that the most common probable cause of stroke was atherosclerotic emboli from the ascending aorta. Palpable lesions in the ascending aorta were noted in a large proportion of stroke patients.
The fourth reason we believe the ascending aorta is the likely source of macroemboli is because of ancillary autopsy data. …….
Note the second reason given above – the independent predictors of stroke. My mother was over 74 yr so fell into the elderly age risk factor group. She was also a type 2 diabetic. She was noted to have a small abdominal aneurysm and some renal artery stenosis on the angiogram (an accidental pickup). So she had three of the four independent risk factors.
REFERENCES
Stroke during coronary bypass surgery: principal role of cerebral macroemboli; Eur J Cardiothorac Surg 2001;19:627-632; Michael A. Borger, Joan Ivanov, Richard D. Weisel, Vivek Rao, Charles M. Peniston
*This blog post was originally published at Suture for a Living*
April 26th, 2009 by Dr. Val Jones in True Stories
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A surgeon friend of mine recently told me a story about a little girl who wandered into the territory of some pit bulls. These dogs were tied up with leashes in the neighbor’s back yard – specifically because they couldn’t be trusted to run loose near children. Tragically, the two year old wandered within their grasp after slipping through a protective kiddie gate and out of the house.
The dogs attacked her viciously, dragging her deeper within their territory and attempted to eat her alive. They tore off both her ears and shredded her chest and limbs. By the time she was discovered she was near death. The girl was rushed to the nearest trauma center – where my friend took her to the OR immediately. He spent the entire night putting the pieces back together, as it were.
A couple of days later, my astute friend noticed her having problems turning her head towards her mothers’ spoon during meal times. That observation triggered him to test her vision – and low and behold the girl was completely blind. A brain CT confirmed the clinical team’s worst fears: at some point during her resuscitation, the girl had a massive stroke, and her entire occipital lobe (the back of the brain) was damaged.
Wondering if there was anything he could do to help the girl, and devastated by what he assumed was a grave prognosis (a lifetime of blindness), my friend called a neuro-ophthalmologist for advice. Much to his amazement, the neurologist told him that her visual deficits were likely to resolve completely, because her brain would simply adapt. Children at very young ages can recover from otherwise devastating strokes because of neuroplasticity – the ability of the brain to rewire itself, and recruit healthy neurons to take over for damaged tissue.
True to the neurologist’s predictions, the little girl regained her site within a year. Fortunately, her body healed extremely well too – and despite thousands of stitches, her scarring turned out to be quite minimal. Today it’s hard to tell that she’s had surgery at all.
This story holds special interest to me, as I too was mauled by a dog when I was a little girl. Although I was bitten in the face, and nearly lost my left eye, I can’t remember the last person who noticed my scars or asked about them. They simply faded with time.
The extraordinary healing powers of young tissue cannot be matched in adulthood. However, some degree of neuroplasticity lives on in each of us, offering hope for brain rehabilitation for everyone – from the forgetful to those with major impairments.
Whether you (or a loved one) have internal or external scars – healing is always possible.
April 16th, 2009 by eDocAmerica in Better Health Network
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Stroke is a major cause of disability and death in the U.S. and worldwide. Modern medicines like statins (and old ones like aspirin) are helpful in preventing both initial and secondary stroke in patients at risk. But, are there simple things you can do to lower risk?
Yes, you say! Well, indeed, you are correct. Twenty thousand men and women (age range, 40–79) without histories of stroke or heart attack were recently analysed in the U.K. for the effect of 4 simple behaviors: not smoking, regular physical activity, moderate alcohol intake (1–14 drinks weekly), and high fruit and vegetable intake .
Patients engaging in 3 or 4 of the activities were significantly less likely (2 times!) to suffer a stroke over the next decade. Patients who slipped up a bit and only did 1 or 2 of the activities did have significant stroke risk, though not quite as much as those who sat on the sideline and engaged none of the behaviors.
So, grab the baton and step up to prevent stroke. As always, questions and comments are welcome.
*This blog post was originally published by Jerome Ecker, MD at the eDocAmerica blog.*
March 17th, 2009 by Dr. Val Jones in Humor, True Stories
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Today I was able to give good news to a patient: he was going to be discharged home in 48 hours. He was a feisty elderly man, admitted after having a stroke. His response to the news:
“Well, thanks for telling me, doc. At least I know when I’ll be getting out of here so I’m not stuck in a vacuum, like some kind of science fiction movie.”
