Author: noorali

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Controlling Hypertension Means Preventing Stroke

When was the last time you had your blood pressure checked?

Last week, I wrote in my column that we should learn to recognize early signs of stroke because if you receive clot busting medications within three to 4.5 hours then your chance of survival and living without disability is considerably improved.

So, what can you do to prevent stroke?

There are many things you can do to prevent stroke. One of the most import things you can do is to keep your blood pressure under control. Especially, in the current worsening economic situation.

We know that anxiety does not cause permanent high blood pressure but it can cause dramatic temporary spikes of high blood pressure which can cause damage to our blood vessels and vital organs like heart and kidneys. It can damage the brain and retina. Persistent or recurrent anxiety can make us prone to picking up bad habits like smoking, drinking or eating too much unhealthy food. Combination of these factors can increase our risk of high blood pressure.

Nearly two-thirds of all cases of stroke and one-half of all cases of coronary heart disease are directly related to hypertension. What is scarier is that most cases of hypertension either go undiagnosed or untreated. That is why it is called a silent killer. You may have high blood pressure but may not have any symptoms.

World Health Organization says that hypertension causes seven million premature deaths worldwide each year. Hypertension affects 22 percent of Canadians. It is estimated that 25 percent of the 42 million people with high blood pressure in the United States are unaware that they have hypertension. It is a ticking but silent time bomb ready to explode any time.

The incidence of hypertension increases with age. Most elderly Canadians have high blood pressure – probably due to thickening of blood vessels. No cause is identified in 80 to 95 percent of people with hypertension. This is known as idiopathic or essential hypertension. Others have hypertension due to primary disease of kidneys or due to certain hormonal disorders.

We eat too much and we do not exercise enough. Our blood vessels become harder and less compliant with age. When the blood is pumped out of the heart into less compliant blood vessels, the blood pressure goes up. So the heart has to work harder – and eventually it becomes tired, weak and fails. It silently causes damage to our vital organs and eventually results in heart attack, congestive heart failure, stroke, kidney failure and blindness.

Normally, systolic blood pressure should be less than 140 mm Hg (mercury) and diastolic pressure of less than 90 mm Hg. Blood pressure is lowest in the early morning, rises as the day progresses, and then dips down during the night and earliest hours of the morning.

Hypertension can be prevented and treated with lifestyle changes – with or without medication. Eat a healthy diet, lose weight if you are overweight, do not smoke, limit alcohol intake, eat a low salt diet, minimize sugar intake, do regular exercise, relax and learn to manage stress with laughter and meditation.

If your doctor wants you take pills to control your blood pressure then make sure you take it regularly. Research has shown that 50 per cent of the patients with high blood pressure discontinue their antihypertensive medications by the first year. This is no good.

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Plan Ahead for a Dignified Death

Last week, my friend Evelyn sent me a red rose in memory of my mother. Evelyn also had a question, “Why an elderly lady in a nursing home was denied treatment because her nursing care status was DNR 3?” Let me give you some personal examples to answer the question.

Yesterday (December 1) was my mother’s 88th birthday. But she wasn’t here to celebrate. So the red rose was timely. The red rose and the letters DNR brought back memories of my parent’s last few hours or few days in this world.

In my dad’s case, he had a severe heart attack at home. The paramedics revived him, put him on a breathing machine and transported him to Foothills hospital.

As I was about to leave for Calgary, my dad’s cardiologist phoned me to say that my dad’s chances of recovery were minimal and needed directions regarding resuscitation and how long to prolong his life on a breathing machine. He wanted me to discus the situation with the rest of the family since my dad had not left any written direction regarding such matters. We chose DNR 3.

In my mom’s case the situation was little different. She was diagnosed with terminal cancer. She was given a choice between receiving chemotherapy, with its unpleasantness and no chance of cure vs. tender loving care with no active treatment to avoid unnecessary prolongation of sufferings. My mom was mentally alert and was able to make an informed decision after a family discussion to let nature take its course. That means she elected to be DNR 3.

DNR stands for “do not resuscitate”. DNR provides guidelines for resuscitation levels depending on patient’s condition. Resuscitation care decisions are made by the attending physician in consultation with the patient, if the patient is mentally capable of making that decision. Otherwise the physician has to discuss the situation with the patient’s family members or a legal guardian. If there is no next of kin or a legal guardian then a second physician is consulted.

DNR has three levels: DNR 1, DNR 2 and DNR 3.

Patients on DNR 1 receive total supportive treatment including CPR (cardio-pulmonary resuscitation). The patients receive all aggressive medical, nursing and paramedical intervention including mechanical breathing machine and defibrillation. This status is given to all new patients in acute care unless they have a personal directive which gives clear instructions otherwise.

Patients on DNR 2 have to be deemed to have a poor likelihood of returning to a stable condition after CPR. Patients under this status do not get CPR or mechanical breathing. They receive all other supportive treatment.

Patients on DNR 3 receive comfort measures only as they are deemed to have an illness or condition which does not have a cure or provide a good quality of life. Therefore these patients receive only tender loving care.

The whole purpose of DNR policy is to allow people to die with dignity. That is why it is important to have a personal directive. A personal directive is a legal document you write in case you cannot make your own personal decisions in the future. The document lets you choose another person, an agent, to act on your behalf and make decisions for you when you cannot make them yourself.

You can have a personal directive if you are 18 years or over. Personal Directives Act (December 1, 1997) requires that for a personal directive to be valid, it should be signed, dated and witnessed. For more information you should visit Alberta Seniors and Community Supports (Office of the Public Guardian) website at www.seniors.gov.ab.ca. Their phone numbers: Edmonton office 780-422-1868, Lethbridge office 403-381-5648.

If you do not have a personal directive then you should get one today.

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There Are New Guidelines For Stroke Management

“During a BBQ, a friend stumbled and took a little fall – she assured everyone that she was fine (they offered to call paramedics) … she said she had just tripped over a brick because of her new shoes. They got her cleaned up and got her a new plate of food. While she appeared a bit shaken up, Ingrid went about enjoying herself the rest of the evening.
Ingrid’s husband called later telling everyone that his wife had been taken to the hospital. Ingrid passed away at 6:00 pm. She had suffered a stroke at the BBQ. Had they known how to identify the signs of a stroke, perhaps Ingrid would be with us today. Some don’t die … they end up in a helpless, hopeless condition instead.

A neurologist says that if he can get to a stroke victim within three hours he can totally reverse the effects of a stroke … totally. He said the trick was getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours, which is tough.”

Above two paragraphs are taken from an email sent to me by a friend in Calgary. It is not an uncommon story. Most people know somebody who has been paralyzed or killed by stroke. The good news is there is lot of research going on to prevent stroke. “Research in stroke care is generating new information at a rate that challenges our ability to effect health-system change in a timely manner,” says an article in the Canadian Medical Association Journal (CMAJ).

What is new now is the time window for delivery of thrombolytic therapy (clot buster) for acute ischemic stoke has been extended, from three to 4.5 hours after the onset of stroke symptoms. The CMAJ article says that for a person with stroke, “time is brain,” and earlier treatment is associated with better outcomes. Even if a patient presents later than the 3-hour window, he or she should still be considered for clot busting therapy.

For a better outcome, acute stroke teams and emergency departments must continue to give priority to all suspected stroke patients and follow agreed-upon protocols. Rapid transportation, diagnosis and treatment go hand-in-hand in improving prognosis. Patients with suspected transient ischemic attack (sort of a temporary stroke) or minor stroke, if treated early, can minimize the risk of disability significantly to less than five per cent.

How can you recognize stroke early? If you are a victim of a stroke or you see somebody complaining of some strange symptoms then you can make a rapid diagnosis by following the following check-list:

S: Ask the individual to smile (there should be no drooping on one side)

T: Ask the person to talk (coherently) and stick tongue out to see if it deviates on one side.

R: Ask the person to raise both arms (there should be no weakness on either side).

If he or she has trouble with any one of these tasks, call 911 immediately and describe the symptoms to the dispatcher. Don’t worry if you are wrong. There is no penalty for that. But if you are right then you will save somebody’s life or prevent lifelong disability.

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Proctalgia Fugax Is A Pain In The Butt

A man with pain shooting up his back. (Zoonar/Thinkstock)
A man with pain shooting up his back. (Zoonar/Thinkstock)

You have pain in the butt which comes and goes. You see a doctor. You want to know if you have hemorrhoids or cancer. Well, what else could it be?

There are at least six common causes for rectal and anal pain: pruritus (itch), external thrombosed hemorrhoid (a blood clot), prolapsed internal thrombosed hemorrhoids, fissure (tear), abscess, and fistula (tunnel). Ok, you can add one more condition to the list – proctalgia fugax.

Your next question is, “Doc, what is proctalgia fugax?”

This condition was first described in Ancient Rome over 2000 years ago and still carries the Latin name which translates to “fleeting rectal pain.” It occurs in about 14 percent of healthy people. Seventy five percent of these are women.

Sufferers of this condition often describe waking up from a sound sleep with a sharp pain, often described as stabbing pain “like a knife sticking deep in the rectum.” The pain is usually brief – lasting less than 20 minutes – and disappears as mysteriously as it comes.
Proctalgia fugax falls under the category of “unexplained rectal and anal pain”. Other conditions under this group are levator ani syndrome and coccygodinia.

Let us try and understand some anatomy first.

Colon ends in the pelvis to become sigmoid, rectum and anus. Sigmoid and rectum act as storage area for fecal matter. At a socially convenient place, the anal sphincters (valves) relax to allow us to defecate.

Anal canal is surrounded by two circular muscles known as internal and external sphincters. Rectum is surrounded by and held in place by pelvic floor consisting of a group of muscles called levator ani. Coccyx is the tail end of the spine, not too far from the anal canal.

Proctalgia fugax can begin during sleep, defecation, urination, or intercourse. The character of the pain has been compared to a charlie horse. It may only occur once a year or several times a week. Pain may be severe enough to cause sweating and palpitation. There may be a desire to have a bowel movement, yet pass no stool.

It is thought that a sudden spasm of the levator muscle complex or the sigmoid colon can result in proctalgia fugax. It is believed that people who frequent the toilet are at greatest risk. Professionals, managers, and perfectionists are more likely to be afflicted. Stress and anxiety plays a role in precipitating the pain.

The diagnosis is based almost entirely on the patient’s history. Clinical examination is usually negative. Patients should undergo flexible sigmoidoscopy to screen for other causes of ano-rectal diseases. Careful pelvic and prostate examinations should be undertaken. Ultrasound or CT scan of the pelvis may be necessary.

Patients with levator ani syndrome experience pain for hours to days. The pain is most often constant or rhythmic and may be likened to sitting on a ball or feeling like a ball (or corncob) was inside the rectum. Pain may be caused by defecation, sexual intercourse, sitting for long periods, and stress or anxiety. The pain is probably due to spasm of the pelvic floor muscles.

Coccygodynia is a cramp or ache in the tailbone and typically results from injury to the coccyx or arthritis. Movement of the coccyx can reproduce the pain. Pain from proctalgia fugax, levator syndrome, and coccygodynia may be hard to differentiate.

Treatment is often unrewarding. Some of the measures worth trying are: reassurance, hot baths, bowel regimens, massage therapy, perineal strengthening exercises, pain killers, anti-inflammatory, muscle relaxants, topical nitrates, tranquillizers, calcium channel blockers, acupuncture, and psychiatric evaluation.

Unfortunately, proctalgia fugax is one of the many medical conditions for which there is no good explanation or treatment.

This article was mentioned in my video blog (Had Your Butt Checked Out Lately?) on September 25, 2011.

Topics on my website: Proctalgia fugax and Hemorrhoids.

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