Think you might be having a stroke? Call 911

Most strokes are caused by a blocked artery that starves an area of the brain of it’s blood supply, leading to an abrupt loss of brain function.

Stroke-2-410x214

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This can lead to the sudden onset of:

Paralysis on one side (including a drooping face):

hemiparesis

Loss of vision in one eye or to one side:

Visual loss

Or a change in speech:

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If you think you’re having a stroke, get yourself to the hospital right away!

Why?

There’s a FDA approved treatment for acute stroke which can open up that blocked artery, and increase your chances of getting  better, but only if administered within a few hours of the onset of your symptoms, and even then sooner the better.

When you’re having a stroke, time is brain!

time is brain

However, studies show that less than 5% of acute stroke patients get this clot busting therapy, mostly because they do not get the hospital in time.

A recent study found that only 2/3 of stroke patients came to the hospital by ambulance.   Furthermore, if they did come by ambulance, they were 50% more likely get the clot busting therapy.

ambulance

So, if you think you are having a stroke, ACT FAST, call 911 and get to the hospital right away!

On May 11, 1989, President George Bush signed Presidential Proclamation 5975 designating May as National Stroke Awareness Month at the urging of National Stroke Association.

Since then, the National Stroke Association has been honoring this special time of the year to increase public awareness of stroke in an effort to conquer it.

stroke aware

Check our “events” tab for special stroke awareness month educational events emphasizing this message.

Find out more about Monmouth’s innovative TIA center and certified stroke program.

Another reason to take snoring seriously! Sleep apnea linked to strokes.

sleepdisorder

Sleep apnea, the disorder that causes a person to stop breathing suddenly while sleeping, is already known to increase the risk of high blood pressure, heart failure, and daytime sleepiness.

seep apnea consequences

A new study suggests that the sleep disorder is also linked with small brain lesions and a symptomless form of stroke, known as silent stroke.

In the study, 56 men and women ( aged 44 to 75 years) who’d had a recent stroke or TIA underwent overnight polysomnograms.  91% had sleep apnea.

Furthermore, having more than five episodes of sleep apnea in a night was linked with having multiple extra “silent strokes” on their brain imaging studies.

silent stroke

Silent strokes don’t cause any symptoms as they occur, so a person typically doesn’t know he or she has suffered one, but they can eventually lead to memory loss and difficulties with walking, as their effects accumulate over the years.”

Yet another reason to take the on-line sleepiness test, and if your score is >10 see a sleep specialist and/or get an overnight polysomnogram in a certified sleep laboratory.

Memory Loss? Better check that medication list!

Memory Loss

Alzheimer’s disease is the commonest cause of memory loss and dementia.   We do not yet fully understand what causes Alzheimer’s.  However, we do know that the neurotransmitter acetylcholine is important in brain processing and memory.  We also know that the acetylcholinesterase inhibitors (drugs like Aricept<donezepil> , Exelon <rivastigmine> and Razadyne <galantamine>), which inhibit the breakdown of acetylcholine, do provide a symptomatic improvement in affected patients.

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acetylcholine

 

It is also known that many drugs can cause and/or exacerbate memory loss in elderly patients:

Anticholinergics block the effects of acetylcholine, causing confusion. They also negate the beneficial effects of aceylcholinesterase inhibitors in Alzheimer’s patients.  These drugs are commonly prescribed for urinary frequency and urgency, and include Ditropan <oxybutynin> and Vesicare <solifenacin>.  The tricyclics, including Elavil <amitriptyline> and Pamelor <nortriptyline>, commonly prescribed for insomnia and headaches, also have anticholinergic properties.

Benzodiazepine drugs like Xanax <alprazolam> Restoril <temazepam> and Klonopin <clonazepam>, most commonly prescribed for anxiety and insomnia, can also cause and/or exacerbate memory loss because of drowsiness and inattention.

A recent study of Alzheimer’s patients living independently in the community showed that as many 17% were taking anticholinergic drug and almost 9% were taking benzodiazepines.

As if that wasn’t bad enough, 16% of patients were taking both an acetycholineresterase (cholinergic) and an anticholinergic drug at the same time!

The bottom line here is that you should always bring a complete and updated list of all your medications with you to doctors appointments!

med list

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Click here for a link to the full article.

Post-operative peripheral neuropathy

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Post provided by Kevin Turezyn, Drexel University College of Medicine Class of 2013:

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While the overall risks of undergoing a procedure involving general anesthesia have decreased dramatically over the last 25 years, there is one phenomenon that still puzzles both anesthesiologists and surgeons: post-operative peripheral neuropathies.

Why a patient undergoing an appendectomy would wake up with weakness in their arm is still in large part a mystery. Luckily most patients recover fully, but a small subset suffer from permanent damage.

While relatively infrequent, peripheral nerve injury after anesthesia is one of the largest sources of professional liability for anesthesiologists. Estimates of its frequency range from .03% to .11% of patients who undergo anesthesia.

Interestingly, despite numerous attempts to decrease its incidence, anesthesiologists have had little success.

While the exact cause is unknown, many believe that it relates to patient positioning. There are several points in the body where nerves run very close to the surface leaving them vulnerable to injury. For example, the most commonly injured nerve is the Ulnar nerve of the arm. When this nerve goes through the elbow, it is very close to the surface where it has little body tissue for protection. People commonly hit this nerve in daily life, giving them a painful sensation called hitting your “funny bone”. Other commonly injured nerves include the radial nerve (compression in the spiral groove against the humerus), brachial plexus from traction on the arm, sciatic nerve in the buttock and peroneal nerve against the fibula head.

The American Society of Anesthesiologists has published guidelines for prevention of perioperative peripheral neuropathies. The guidelines focus on pre-operative assessment for patients who are at higher risk ( diabetics, alcoholics, patients with peripheral vascular disease) as well as proper positioning of the extremities and adequate padding.

Click here for the full guidelines.

positioning

When peripheral nerve injury does occur, it frequently resolves on its own, although this can take take several months. During this time, there is little that can done to speed recovery. Physical therapy is often recommended to prevent muscle contractures and atrophy during this time period.

If a patient feels that they suffered a nerve injury during surgery, it is important that they be evaluated right away by a trained neurologist. Testing such as an electromyogram (EMG) can be done to determine the location of the injury and prognosis for recovery.

cts emg

Expensive Drugs Could Bankrupt Medicare!

Conceptual photo  illustrating expensive drugs and medicines

The United States spent about $98 billion on pharmaceuticals in 2006. This is despite 10% less drug use than other countries.  The problem is that our drugs, on the whole, cost about 50% more than other countries, 77% more for brand name medications.

Take the Lilly drug Cymbalta, for example – the average cost for a 1-month supply in the USA is $176, compared to $113 in Canada and $47 in France:

Think that’s expensive?  Sanofi will soon launch Lemtrada (alemtuzumab), an M.S. treatment that costs $60,000 per year. It will compete against Gilenya from Novartis, which is already on the market at $40,000 per year.

Why?  Some say that it’s because we’re wealthier and need to subsidize for the rest of the world. But even if we paid more based on our relative wealth, it would come to about a 30% premium, not the 77% we do pay. Some say that it’s because we in the US subsidize the massive research and development for drugs. But the entire bill for R&D for the pharmaceutical industry was less than $50 billion in 2006, far less than the “extra” we paid for drugs.  Some say it’s because we are subsidizing massive marketing in the US, which might be upwards of $40 billion in 2006. Again, far less than the “extra” amount.

Critics of pharmaceutical companies point out that only a small portion of the drug companies’ expenditures are used for research and development, with the majority of their money being spent in the areas of marketing and administration. The pharmaceutical industry has thousands of Washington lobbyists to protect their interests, and actually spent $855 million, more than any other industry, on lobbying activities from 1998 to 2006.

Prescription drug prices have become a real political issue in the United States.

Many third party payers can negotiate lower prices to control their low costs, but this causes pharmaceutical companies to raise their retail prices to offset costs.

Using a mail order pharmacy for a 3-month drug supply can save as much as a 29% in out-of-pocket costs and 18% in total prescription costs.

To save even more money, 10 million U.S. citizens bring in medications across land borders from Canada and Mexico each year.  Other patients shop on-line at lower cost overseas pharmacies, and an additional 2 million packages of medications arrive annually by international mail from Thailand, India, South Africa every year.

Should “mild” sleep apnea be treated?

Have you had a sleep study and were told it showed “mild” sleep apnea, but treatment wasn’t necessary?  This very issue is often debated within the sleep community.  The presumption among some practitioners and patients is that the perceived “burden” of CPAP probably outweighs the benefit of treatment.

CPAP

Sleep specialists are well aware that even patient’s with mild sleep apnea, usually defined by an apnea index of less than 15, can have a benefit from treatment with CPAP.  A recent study gives evidence for this.

Published in the journal, Thorax, the MOSAIC randomized trial sought to determine the effect of CPAP treatment on patient’s with mild OSA.  The determined effect was based on questionnaires regarding daytime sleepiness and function, as well as a variety of physiologic parameters, including blood pressure, blood sugar control, and cholesterol that signify vascular risk.

At 6 months, the patient’s were reassessed.  Even with a median CPAP usage of only about 2.5 hours per night, there was a significant improvement in daytime sleepiness scores.  There was no detected effect on vascular risk.  An obvious limitation of the study is that followup was only at 6 months, when the average usage of CPAP was still suboptimal.

Nevertheless, this study brings up a number of important points:

  • First, CPAP works!  The prospect of wearing a mask on your face to sleep may sound daunting.  With an experienced sleep specialist helping out, most patients can make get through those first few weeks.  They can actually learn to love it for the simple reason that it can make you feel better.  There are literally hundreds of different types of masks and one can usually be found that’s comfortable for you.  As this study shows, even patients with “mild” OSA can get a benefit from using it.
  • Second, health benefits from using CPAP are real.  Though the effect of CPAP on blood pressure, cardiovascular, and cerebrovascular  risk in mild OSA is modest, the risk reduction in people with moderate to severe OSA is very significant.

The important point here is that if you have symptoms of sleep apnea, such as excessive daytime sleepiness or snoring, and your sleep study shows only “mild” disease, treatment can work. 

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Find out more:

Sleep disorders in general,

Monmouth’s Sleep Lab,

Monmouth Neuroscience Institute’s Comprehensive Sleep Medicine Program.

CIDP Patient Impoves with Treatment

This 11-year-ol girl had a 4-month history or progressive proximal leg weakness leading to falls and difficulty with stairs. There was no back pain, numbness in the legs or difficulty with badder or bowel control.

Her exam showed leg weakness, absent reflexes and normal sensation.

Her serum CK was normal.  Her EMG showed features of acquired demyelinating neuropathy, most notably absent F-waves.  Her CSF showed a mildly elevated protein level without cells (“albuminocytologic dissociation”).  She was treated with a course of intravenous immune globulin and made a remarkable recovery within 4-weeks.

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Chronic inflammatory demyelinating polyneuropathy (CIDP)

CIDP is an acquired immune-mediated inflammatory disorder of the peripheral nervous system, causing demyelination, conduction slowing and conduction block:

Affected nerves fail to respond to stimuli causing progressive muscle weakness, loss of deep tendon reflexes (areflexia), fatigue, and abnormal sensations.

Most cases show evidence of demyelinating neuropathy on electrodiagnostic studies and albuminocytologic dissociation in the cerebrospinal fluid.

Early diagnosis and treatment is important in preventing irreversible axonal loss and improving functional recovery.

However, CIDP is probably under-recognized and under-treated due to its variable presentation and the limitations of clinical, serologic, and electrophysiologic diagnostic criteria.

Consultation with a sub-specialty trained neuromuscular physician is critical.