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 6682consecutive coronary bypass patients who only had the CABG procedure and not other simultaneousprocedures, such as carotid endarterectomy.
They list the possible sources of the emboli as the ascending aorta, carotid arteries, intracerebralarteries, or intracardiac cavities. They state that they believe the most likelysource is the ascending aorta, for the following reasons:
First, the ascending aorta is the site of surgical manipulationsduring CABG, whereas mechanical contact is not made with theother potential sources of emboli. Embolization of atheroscleroticdebris is most likely to occur during aortic cannulation/decannulation,cross-clamp application/removal, and construction of proximalanastomoses. However, embolization of atherosclerotic debrismay 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, previousstroke/TIA, diabetes, and peripheral vascular disease –are strongly associated with atherosclerosis of the ascendingaorta.
Third, our chart review suggested that the most common probablecause of stroke was atherosclerotic emboli from the ascendingaorta. Palpable lesions in the ascending aorta were noted ina large proportion of stroke patients.
The fourth reason we believe the ascending aorta is the likelysource 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.
Aspirin? – Yes, I should take that to prevent heart attack and stroke, right??
Well……perhaps. A new study (called a meta-analysis), the largest comparative trial of its kind, shows that being overzealous about aspirin use for prevention of initial heart attack and stroke may be unsubstantiated.
Specifically 95,000 subjects were evaluated, producing 1671 vascular events in the aspirin group and 1883 in the control group. Aspirin was associated with an absolute reduction of 0.06% heart-related events per year. Correspondingly, aspirin did not significantly reduce ischemic stroke risk, but researchers noted a borderline-significant increase in hemorrhagic stroke. Aspirin also increased the incidence of bleeding outside the brain. Overall, aspirin was not associated with a significant reduction in vascular death.
What does it mean? The advantages of aspirin in low risk patients are scant. As cardiovascular risk factors (like smoking, high cholesterol, high blood pressure, diabetes, family history of early stroke/heart attack) pile up, aspirin gains a bit more support, though there is a modest associated bleeding risk.
We will be following this data and it’s analysis further. In the meantime, it may be reasonable to discuss things with your doctor, or perhaps cut aspirin dosing to the appropriate lowest dose (81mg in most patients).
Want the original?
See Collins R et al. for the Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009 May 30; 373:1849. We will post the appropriate links after publication to make it easier.
*This blog post was originally published at eDocAmerica*
Urinary incontinence affects millions of women – 38% of women over the age of 60 – yet only 45% ever seek help for it. Men suffer from the problem too but at about half the rate. Only 22% of men seek help.
Why is this a taboo subject? One reason is that it’s an embarrassing – even infantilizing – problem. But patients’ shame is, well, a shame. Because urinary incontinence – the involuntary leakage of urine – can often be treated quite successfully. The first step is to make a proper diagnosis. One common type is “urge incontinence” – the bladder contracting when a person isn’t ready to urinate and can’t get to the toilet fast enough. Another common type, especially after childbirth or in athletes, is “stress incontinence.” It happens when there is a weakness in the pelvic muscles supporting the bladder and urethra (the structure through which urine exits the bladder), causing the urethra to lose its seal and allowing urine to escape when there is increased pressure on the bladder (e.g. coughing, sneezing, laughing, lifting, or exercise). As women get older, it’s more likely they will develop urge rather than stress incontinence. A very simple three question test has been created to help with the diagnosis.
It’s important to get a complete, head to toe medical evaluation because urinary incontinence may be a symptom of an underlying condition (e.g., neurological problem, diabetes, urinary tract infection, chronic bladder inflammation, or even a tumor) or may be a result of medication. Talk to your primary health provider and/or gynecologist. If needed, a specialist (e.g., urologist or urogynecologist) can be consulted.
Treatments for urge incontinence include bladder retraining and pelvic muscle exercises, medications to relax the bladder, and decreasing fluid intake. Approaches to stress incontinence include weight loss if obesity is present, a vaginal pessary, and surgery.
In today’s segment of CBS Doc Dot Com, Dr. Lori Warren and Dr. Jody Blanco, gynecologists with expertise in urinary incontinence, discuss the problem. You’ll meet a woman who overcame her embarrassment, sought help from Dr. Blanco, and is now symptom free after surgery.
There are several online resources on the subject, listed at the end of an excellent discussion in the online medical database, UpToDate.com.
One of our most revered faculty members, Lee Archer, MD, a neurologist, provided a copy of the handout he gives to his headache patients. With his permission, I adapted it for use with my own patients. I thought it was so good that I asked him if I could publish it on my blog so that others could benefit from his advice.
Headaches are incredibly common and usually frustrating for providers. It has become increasingly evident that chronic or frequently occurring headaches are often virtually impossible to identify as either “migraine” or “tension” headaches and often simply are called “chronic headaches”. Treatment often becomes a revolving door of trying new medications that sometimes work, but more commonly don’t. And, even worse, many headache patients gradually simply become dependent on addictive pain medications just to try to cope with their often daily discomfort.
But, there are some really basic things about dealing with chronic headaches that we should never forget to try. So, without further ado, here is his advice:
Ten Steps to Overcoming Your Headaches
There are some things that everyone can do to help their headaches. There are a number of things you can besides just take medication to help their headaches. If someone follows all of these directions, the need for prescription medication is often dramatically reduced if not eliminated.
1. First and foremost, taking pain medication everyday is definitely not a good idea. Daily pain medication tends to perpetuate headaches. This is true for over-the-counter medications like Excedrin and BC powders, as well as prescription medications like Fiorinal, Midrin, and “triptans” like Imitrex, Zomig, Relpax, Frova, etc. Exactly why this occurs is unclear, but it is a well established clinical finding. Anyone who takes pain medications more than twice a week is in danger of perpetuating their headaches. Occasional usage of pain medications several times in one week is permissible, as long as it is not a regular pattern. For instance, using pain medication several days in a row during the perimenstrual period is certainly permissible.
2. Regular exercise helps reduce headaches. Exercise stimulates the release of endorphins in the brain. These are chemicals that actually suppress pain. I encourage people to aim for at least 20 minutes of aerobic exercise (like walking or swimming) five days a week if not daily. In addition to helping reduce headaches, this also will prolong your life because of the beneficial effects on your heart.
3. Stress reduction is a definite benefit in reducing headache frequency and severity. Headaches are not caused by stress alone, but can make most headaches worse. There are no easy answers for how to reduce stress. If it is severe, we can consider referral to a therapist for help.
4. Too much or too little sleep can trigger headaches. Pay attention to this, and note whether or not you are tending to trigger headaches from sleeping too little or too much. People differ as to how much sleep is “right” for them.
5. Caffeine can precipitate headaches. I encourage patients to try stopping caffeine altogether for a few weeks, and we can decide together whether or not caffeine might be contributing. Abruptly stopping all caffeine can trigger headaches, too, so try to taper off over a week.
6. NutraSweet (aspartame) can cause headaches in some people. If you are drinking multiple servings/day of beverages containing NutraSweet you might consider trying to stop that, and see if your headaches respond.
7. There are some other foods they may trigger headaches in some people. Usually people learn this very quickly. For instance, red wine will precipitate migraines in many people, and chocolate, nuts, hot dogs and Chinese food triggers headaches in certain cases. I generally don’t advise omitting all of these foods, unless you notice a pattern where these foods are causing headaches.
8. If I give you a prophylactic medication for headaches, you should take it daily, as prescribed. If you have trouble tolerating it, please let me know and we can consider using something else. No prophylactic medication works in every patient with headaches. Generally, each of the medications works in only about 60% of people. Therefore, it is not uncommon to need to try more than one medication in any given patient. We must give any of these medications at least four to six weeks to work before giving up on them. It generally takes that long to be sure whether or not a medication is going to work.
9. Keep a calendar of your headaches. Use a standard calendar and mark the days
that you have a headache, how severe it is on a scale of one to ten, what you took
for it and how long it lasted. Also note anything that you think could have
precipitated it. By keeping this over time we can tell if our efforts
are helping.
10. Riboflavin (vitamin B2) 400mg daily helps prevent migraines in many people. It
comes in 100mg size tablets, so you will need to take four of them each day. You
can add it to anything else we try. You do not need a prescription for it.
Do you have chronic headaches? If so, I challenge you to apply these ten principles, then come back and provide a comment on this blog post!
Thanks and good luck!
*This blog post was originally published at eDocAmerica*
The answer is “yes.” An estimated 5.3 million Americans suffer from Alzheimer’s Disease, the majority – 5.1 million – over the age of sixty five. Research suggests that less than 35 percent of people with Alzheimer’s or other dementias are properly diagnosed. Early diagnosis is crucial for many reasons, including:
1) There are medications available today that can reduce symptoms in many people – at least temporarily – and improve the daily lives of patients. There are also trials of new drugs that researchers hope will slow or stop the underlying processes that cause Alzheimer’s in the first place.
2) Knowing what’s going on can lessen anxiety and allow for planning – not only for patients but for their families, friends, and caregivers.
3) Although Alzheimer’s causes 60-80 percent of dementia in patients over 65, there are other causes that need to be considered, especially potentially reversible ones due to medications, alcohol, low thyroid, low B12, depression, and infections. Dementia can also be caused by tumors, increased pressure, blood clots and other abnormalities within the head itself that can be detected by a CT or MRI of the brain. And patients with “vascular dementia” due to problems such as multiple small strokes (that may not have caused any other symptoms) can be treated with measures that include medications and lifestyle adjustments to lower their cardiovascular risk.
The Alzheimer’s Association is a terrific resource for information about Alzheimer’s and other forms of dementia. Its website includes ten warning signs for Alzheimer’s Disease.
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