Author: noorali

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Stroke Misdiagnosis in Young Adults on the Rise

Piazza dei Miracoli (English: Square of Miracles), formally known as Piazza del Duomo (English: Cathedral Square), is a walled 8.87-hectare area located in Pisa, Tuscany, Italy. (Dr. Noorali Bharwani)
Piazza dei Miracoli (English: Square of Miracles), formally known as Piazza del Duomo (English: Cathedral Square), is a walled 8.87-hectare area located in Pisa, Tuscany, Italy. (Dr. Noorali Bharwani)

A 2009 study by the Department of Neurology and Stroke Program at Wayne State University/Detroit Medical Center found that among 57 young stroke victims, one in seven were given a misdiagnosis of vertigo, migraine, alcohol intoxication, seizure, inner ear disorder or other problems – and sent home without proper treatment.

While the majority of strokes strike people over the age of 65, the incidence of strokes in individuals 50 and younger is on the rise. Because people associate stroke with the elderly, symptoms in younger victims can often be missed or dismissed – even by medical professionals.

What are the signs of stroke?

Recognizing the signs of stroke can be the first step to getting correct treatment. Experts recommend you use the mnemonic device FAST.

Face: is it drooping?

Arms: can you raise both arms?

Speech: is it slurred or jumbled?

Time is of the essence: to call 9-1-1 right away.

How can you be diagnosed and treated early?

For a good outcome early intervention and treatment is important.

A person has symptoms, the paramedics are called and the person is brought to the hospital. The ER physician does clinical examination and investigations and comes to a diagnosis. All this should not take more than one hour.

Once the diagnosis is made the standard of treatment is administration of medication called tPA (tissue plasminogen activator) intravenously. When tPA is promptly administered, it can save lives and reduce the long-term effects of stroke. It needs to be used within three hours of having a stroke.

According to Alberta Health Services, Alberta’s stroke treatment is now reported to be among the fastest in the world. Alberta’s quality improvement program cuts time for life saving drug treatment from 70 to 36 minutes. A similar effort in the United States saw average door-to-needle times in participating hospitals drop from 74 minutes to 59.

The accepted benchmark has been to treat patients within 60 minutes of their arrival at the hospital. The Grey Nuns Hospital in Edmonton currently holds the provincial record with the fastest door-to-needle time – six minutes.

The medication (tPA) was introduced 20 years ago. But the results are not perfect. Although tPA is successful in recanalyzing the blocked artery in up to 78 per cent of cases, this rate of success is dampened by a high rate of acute repeat occlusion leading to an ultimate rate of 33 per cent partial and 30 per cent full recanalization.

Doctors are working on newer methods to treat stroke patients. Now doctors are able to pull a clot from the brain of patients while they are having a stroke. It is called an endovascular procedure or a mechanical thrombectomy. The procedure should be done within six hours of acute stroke symptoms. The entire procedure takes about 10 minutes. This treatment is not available in all centers across Canada.

The message is clear. Whether the patient is young or old, for the best possible results, it is important to identify stroke symptoms and seek treatment immediately.

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Important Things to Know About CPR (Cardio-Pulmonary Resuscitation)

Sunrise at Haleakala Volcano Summit in Maui, Hawaii. (Dr. Noorali Bharwani)
Sunrise at Haleakala Volcano Summit in Maui, Hawaii. (Dr. Noorali Bharwani)

“Bystander CPR is the most important predictor of survival from cardiac arrest,” says an article in the Canadian Medical Association Journal (CMAJ January 9, 2017).

The article is titled “Five Things to Know About Cardio-pulmonary Resuscitation.” Here is the summary.

1. Chest compressions – importance of fast pushes

Chest compressions during CPR should be fast pushes. In adult patients with out-of-hospital cardiac arrest, a large multicentric study has shown patient survival to hospital discharge was highest when compressions were between 100 and 120 per minute.

2. During the use of a defibrillator – importance of peri-shock pauses

During cardiac arrest the heart needs to be shocked with a defibrillator. To do this chest compression has to stop for a brief moment. This is called peri-shock pauses. Peri-shock pauses should be limited to improve survival. High priority is given to minimizing interruptions for chest compressions. It is recommended that total pre-shock and post-shock pauses in chest compressions be as short as possible.

Studies have shown survival is higher for those patients who received pre-shock pauses of less than 10 seconds and total peri-shock pauses of less than 20 seconds during CPR. Peri-shock pauses should be minimized during CPR by performing compressions while the defibrillator is charging.

3. Interrupted or continuous CPR strategy?

Bystander CPR is the most important predictor of survival from cardiac arrest. Any interruptions in chest compressions are associated with reduced blood flow and worse survival.

For this reason, and because ventilation (mouth to mouthing breathing) is a difficult skill to acquire for those who are not health care professionals, the guideline update recommends that members of the public provide uninterrupted continuous chest compressions.

Trained rescuers should provide 30 chest compressions that are interrupted by no more than 10 seconds to provide two ventilations (mouth to mouth breathing).

4. Role of medications during cardiac arrest

Should we use vasopressin or epinephrine during resuscitation? The aim is to improve return of spontaneous circulation and improve survival.

Vasopressin is a hormone. Its two primary functions are to retain water in the body and to constrict blood vessels to raise blood pressure.

Epinephrine, also known as adrenaline, is a hormone. It plays an important role in the fight-or-flight response of the body by increasing blood flow to muscles, output of the heart, pupil dilation, and blood sugar. As a medication it is used to treat a number of conditions, including anaphylaxis, cardiac arrest, and superficial bleeding.

The CMAJ article says vasopressin offers no advantage over epinephrine in cardiac arrest.

There is limited evidence to suggest that vasopressin and epinephrine can improve return of spontaneous circulation. Because simplicity is important during resuscitation efforts, the guideline update specifically recommends that epinephrine be administered as soon as possible following onset of cardiac arrest.

5. Maintain patient’s temperature during cardiac arrest

A target temperature should be maintained in the post-cardiac arrest period.

All adult patients who are comatose with return of spontaneous circulation following cardiac arrest should receive targeted temperature management. The guideline update recommends selecting and achieving a single target temperature between 32°C and 36°C, which should be maintained constantly for at least 24 hours.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Women with Breast Cancer Can Modify Their Lifestyle to Improve Prognosis

Sunrise at the World's Tallest Tepee, Medicine Hat, Alberta. (Dr. Noorali Bharwani)
Sunrise at the World's Tallest Tepee, Medicine Hat, Alberta. (Dr. Noorali Bharwani)

“Although more than 90 per cent of patients with breast cancer have early stage disease at diagnosis, about 25 per cent will eventually die of distant metastasis,” says an article in the Canadian Medical Association Journal (CMAJ February 21, 2017).

Women with breast cancer would like to improve their prognosis and live long. Making positive lifestyle changes can improve long-term prognosis and be psychologically beneficial, since the feeling of loss of control is one of the biggest challenges of a cancer diagnosis.

So which lifestyle changes can be recommended to patients in addition to standard breast cancer treatments?

The CMAJ article reviews the role of lifestyle factors, particularly weight management, exercise, diet, smoking, alcohol intake and vitamin supplementation, on the prognosis of patients with breast cancer. Here is the summary.

Weight management

Weight gain during or after breast cancer treatment increases the risk of recurrence and reduces survival, irrespective of baseline body mass index (BMI). Patients who are obese or overweight at breast cancer diagnosis have a poorer prognosis. So lose weight.

Physical activity

Physical activity can reduce breast cancer mortality by about 40 per cent and has the most powerful effect of any lifestyle factor on breast cancer outcomes. At least 150 minutes per week (about 30 minutes a day) of physical activity is recommended, but less than 13 per cent of patients with breast cancer attain this. So exercise more.

Diet

Western-style diets (high in processed grains, processed meats and red meat) and prudent diets (high in fruits, vegetables, whole grains and chicken) have similar rates of breast cancer recurrence. Diets rich in saturated fat, especially from high-fat dairy products, may be associated with increased breast cancer deaths. Soy products have not been found to increase breast cancer recurrence and may actually reduce it. Eat less and stop eating fatty food.

Smoking

Recent evidence has shown a strong association between a history of smoking and breast cancer mortality. Women who quit smoking after diagnosis of breast cancer have higher overall survival and possibly better breast cancer–specific survival. So quit smoking.

Alcohol intake

Findings are too inconsistent to conclude that alcohol consumption affects breast cancer outcomes. However, limiting alcohol consumption to one or fewer drinks per day reduces the risk of a second primary breast cancer.

Vitamin supplementation

Moderate increases in dietary vitamin C or oral supplementation may reduce breast cancer mortality, but randomized trials are needed to confirm these findings. Vitamin E supplementation is not associated with breast cancer outcomes. Low levels of vitamin D at diagnosis have been associated with an increased risk of breast cancer deaths. However, randomized trials are needed to determine whether supplementation improves prognosis. One multivitamin a day and Vitamin D 2000 units a day is good for your health.

So the message is clear – make positive life-style changes like exercise more, lose weight and eat healthy. And keep smiling.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Self-Monitoring of Blood Glucose in Diabetes

A tree in Maui. (Dr. Noorali Bharwani)
A tree in Maui. (Dr. Noorali Bharwani)

Diabetes mellitus or simply called diabetes is a chronic, lifelong condition that affects our body’s ability to use the energy found in food. This happens when our body’s capacity to produce insulin is diminished.

There are two types of diabetes – not counting gestational diabetes that occurs during pregnancy.

Type 1 diabetes is usually diagnosed in children and young adults, and was previously known as juvenile diabetes. Only five per cent of people with diabetes have this form of the disease. The body is not capable of producing insulin.

Type 2 diabetes is the most common form of diabetes. In this situation the body produces insulin but the body does not use insulin properly. Eventually, the pancreas that normally produces insulin fails.

Individuals with diabetes have to check the blood sugar levels regularly to make sure it is within normal range. If the levels are too high then it can cause many complications. Instead of going to a lab for blood tests diabetic patients can now do their own blood tests and adjust their own insulin dosage.

Consumer Report (Blood Glucose Meter Buying Guide) says today’s blood glucose meters are smaller, faster, and come with more features than ever before. They’re also more accurate than blood glucose meters of years past. That’s good news for approximately 30 million North Americans with diabetes.

Why is it so important for diabetics to monitor their blood sugar levels?

Controlling blood glucose is key to managing diabetes and preventing complications. Test results help patients make adjustments to their diet, exercise routine, and diabetes treatment plan, which can help lower the risk of seizures, blindness, kidney disease, and nerve damage. There are dozens of models available priced between $10 and $75.

The Consumer Report warns don’t just look at the retail price of the meters alone. What makes blood glucose monitoring expensive is the test strips that you might use many times a day. At $18 to $184 per 100 test strips, the cost can add up to about $265 to $2,685 a year for people who test four times a day. Also there is a learning curve to make sure you get a full value for your health and investment.

Does regular monitoring of your blood sugar make your health better?

Xiang and colleagues (Journal of Diabetes Science and Technology, July 2014) says the blood glucose meter is the most successful and widely used portable device for point-of-care tests. The device has more than 50 years of technology development. So the device has stood the test of time. Regular self-monitoring of blood glucose levels in diabetics play a key role in preventing complications in the short, medium and long term.

How do you decide which meter to buy?

One way is to ask your friends who have similar health issues. Ask your doctor, nurse, dietician or individuals who work in diabetic clinics. See what the Consumer Reports has to say. Experts at their National Testing and Research Center tested 25 models to see which ones perform best.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!