Stroke

Dear Dr. B: What is meant by “brain attack”? Is it something to do with acute stroke? Is there a treatment for acute stroke in Medicine Hat? Yours, Afraid to Stroke (ATS).

Dear Mr. ATS: When blood supply to the heart is cut off then it is “heart attack”. When blood supply to the brain is cut off then it is “brain attack”!

One of the common reasons for a heart attack is a clot in coronary artery. One of the common reasons for a brain attack is a clot in one of the brain arteries.

Many lives have been saved by administrating clot-busting drugs to a heart attack patient within the six hours (window of opportunity) of starting the symptoms of chest pain. Similarly, the window of opportunity for brain attack is three hours.

Brain attack, if not recognised or treated early, will lead to stroke (paralysis). As many of us know, stroke leads to significant disability, dependence, complications and sometimes death.

Until recently, there was no good treatment for acute stroke. But in the last three to four years, significant work has been done to show that if clot-busting drug (tPA) is given to patients within three hours of starting the symptoms of paralysis, then the chances of full recovery are significantly improved.

The problem is, when a person experiences sudden weakness or numbness in the arm or leg, or has sudden visual disturbance then he will wait, hoping that it will improve. Sometimes it does – called transient attack. But quite often it may not and by the time he calls the paramedics it is more than three hours. Sometimes a day or two has gone by. Then that person is not eligible for clot-busting treatment.

So it is important for an individual, his family, friends or co-workers to recognise symptoms of stroke, call an ambulance and rush to the hospital emergency within couple of hours of starting the symptoms. Otherwise we lose that window of opportunity.

Do we have treatment (clot-busting medication) for acute stroke in Medicine Hat?
Yes. A protocol for the treatment of patients with acute stroke, who show up at the hospital within three hours of onset of symptoms, was established recently at the Medicine Hat Regional Hospital. So far three patients have been treated successfully. These patients would otherwise have been paralysed and institutionalized for long-term rehabilitation.

Is this a well-established and safe treatment?

Some people think this is still controversial. But a recent review article (September 7) in the New England Journal of Medicine says: “Safe and effective treatment is now available for patients with acute ischemic (where blood supply is cut off) strokes. Intravenous thrombolysis (clot-busting) with tPA is safe and improves outcome if treatment is initiated within three hours after the onset of symptoms”.

Nothing in life is hundred percent safe. Every treatment has likely complications. But two things are important: early recognition of symptoms of stroke and rushing to the hospital emergency within three hours. Otherwise, you do not benefit from clot-busting treatment.

In the next column, we will explore this subject little further, explain the symptoms, look at the likely complications of the treatment and examine the work done in Calgary with the help of Heart and Stroke Foundation.

So Mr. Afraid to Stroke, help is there if you seek it on time!

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Volunteerism

What makes you happy?

While you are thinking about it, let me tell you what makes Evelyn Stall happy.

Evelyn is one of the very happy persons I have met. From time to time, she drops by my office at the Palliser Health Authority. She wants to know how I am doing. How is my family doing? And then she will ask: how is mother? Referring to my mother’s health that was the subject of one of my columns. Then I just relax and listen to her gentle soft voice. And if you can see through her dark glasses then you can observe that mischievous twinkle in her eyes. Her stories and homilies are very funny to very serious.

She is like a cheerleader to me. Every time she talks to me I feel happy. I develop a renewed sense of purpose in life. She has a capacity to inspire you to do things that are good for others. That is Evelyn Stall, a lady with unselfish and unlimited desire to help people. A true volunteer. And I think that is what keeps her happy.

A volunteer is one who enters into or offers himself for any service of his own free will. We are all volunteers in one-way or the other. We do not get paid for everything we do. Consciously or unconsciously we volunteer our time to our school, hospital, church, association, society, sorority or for a cause which we firmly believe in. When we do this, we don’t even think of getting paid. We feel it is our duty to help.

Why do people volunteer?

I think the primary reason is unselfish desire and interest to care for the welfare of others. Some people volunteer because they want to do something in their retirement. They want to continue to be useful in society. Which is healthy for the giver and the recipient of the volunteer service. Volunteering is a win-win situation.

Some people argue that volunteerism is dead. They think people are working harder to make ends meet and have no incentive or desire to provide free service. They have less free time to devote to the poor, the sick and the needy.

So, the news of the opening of the Volunteer Centre at 856 – Allowance Avenue caught my attention. And I was quite happy to see that Evelyn Stall and her associates’ perseverance had borne fruit. It is going to be the principal volunteer centre in Medicine Hat and many local societies will benefit from the training program being established at the Centre.

I had the pleasure of visiting the Centre given to Volunteerism in Action Association rent-free by REDI Enterprises. Pam Wagner and her associates gave me a tour. I was impressed the way the old bottle depot has changed. No more smell of old beer bottles! Instead, tastefully furnished large meeting rooms with big windows. There are fresh apples to welcome new volunteers. There is air of enthusiasm and happiness!

Happiness is a very subjective thing. If helping people is your kind of happiness then phone Pam Wagner at 528-1799. She will match you up with a society that is looking for some body like you. Your happiness will rub onto many people who will be ever so grateful that you made that phone call. So do it now while you are finishing this column. Let there be happiness everywhere! And you will be the source of that happiness!

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Stomach Bugs 2

Mr. Bugged is still worried about the bugs that have been bugging his stomach. As you may remember, the last column was bugged with H. pylori bacterium in response to a question from Mr. Bugged. But Mr. Bugged feels that the column did not completely answer his question. He is not sure if the debugging process was medically indicated in his case and whether it has worked.

Mr. Bugged is having sleepless nights worrying about these bugs. He thinks that the bugs, in the middle of the night, crawl up his oesophagus and have a late night party in his mouth. Well, Mr Bugged, let me assure you that nothing like that has been reported in the scientific literature.

Mr. Bugged says that his stomach rumbles every time he has a meal. He wonders if the bugs are eating away his food. Starving him of essential nutrients. Again, this is not true.

The last column said that H. pylori should be treated if only a person is proven to have an ulcer in the stomach or duodenum. But Mr. Bugged did not have an ulcer. Mr. Bugged is upset with his doctor. The doctor had given him two antibiotics and an acid suppressing expensive drug. Mr. Bugged’s diagnosis? Non-ulcer dyspepsia with H. pylori infection.

Was Mr. Bugged’s doctor wrong? Not really. Mr. Bugged, your doctor must have carefully assessed your symptoms and findings before prescribing the medications. Let me explain the term non-ulcer dyspepsia and the controversy surrounding the treatment of this condition when associated with H. pylori infection.

The term “dyspepsia” is derived from the Greek word dys (bad) and pepsis (digestion). Symptoms of dyspepsia include upper abdominal pain, discomfort, early satiety, bloating, nausea and vomiting. About 30 percent of the population suffers from this but only 20 percent of them seek medical help.

The question is – is H. pylori the cause of dyspepsia? No, the jury is still out on that. Then why treat H. pylori in patients who have no ulcer? This is controversial.

A review article, published in the New England Journal of Medicine, November 1988, says that in 8 of 16 studies, the eradication of H. pylori significantly improved symptoms in patients with non-ulcer dyspepsia. And a recent review article (September 16) in the British Medical Journal says that H. pylori eradication treatment was significantly superior to placebo in treating non-ulcer dyspepsia, one case of dyspepsia being cured for every 15 people treated. Is this a good reason to prescribe medications to get rid of H. pylori in patients with no ulcer? Depends on individual cases.

So, Mr. Bugged, if your symptoms have disappeared after the treatment then your doctor was right. If not, then atleast he tried as long as he explained to you his reasons.
So have a good sleep and enjoy your meals. One day, hopefully, we will have an answer for you.

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Stomach Bugs

Dear Dr. B: My doctor says I have bugs in my stomach. He gave me antibiotics to kill the bugs. Can you please tell me more about these bugs? Where do they come from? How did I get them? Will I pass them to my family? What are my chances of getting them again? Yours, Mr. Bugged!

Dear Mr. Bugged: The bug (bacterium) is called Helicobacter Pylori (H. pylori). The discovery of this bacterium in 1982 has changed how we think about ulcers and non-ulcer symptoms of the stomach and duodenum. Despite significant research and advances in understanding this organism, its cause remains poorly understood.

Let us start with a short history. Once upon a time, most ulcers in the stomach and duodenum were thought to be due to acid produced by the stomach. For more than hundred years, thousands (could be millions) of people all over the world underwent surgery to reduce acid in the stomach, to get rid of the ulcers and prevent their recurrence.

The results of these surgeries (there were variety of them) were not always satisfactory. There were numerous complications and side effects. There were many unhappy patients and surgeons. Then, we saw some newer drugs come in the market to reduce the acid in the stomach. This was 25 years ago. It started with tagamet and now we have a variety of them, better and stronger like losec, pantaloc, prevacid etc.

These drugs did considerably cut down the number of surgical procedures for peptic ulcer disease. But the recurrence rate of ulcers continued to be high unless the patient stayed on the pills for a long time. This made patients unhappy, as the pills are expensive. Thus the compliance rate was poor.

So, what about H. pylori?

Peptic ulcer disease affects about 10 percent of the population at some time in their lives. There are approximately 2500 new cases each year in Alberta. Over 90 percent of duodenal ulcers and 70 percent of gastric ulcers are associated with H. pylori infection. But only about 15 percent of patients with H. pylori infection will develop peptic ulcer disease or cancer of the stomach as a consequence of their infection. Some ulcers are caused by aspirin or NSAID (non-steroidal anti-inflammatory drugs).

Where do the bugs come from?

Only proven reservoir for H. pylori is the human host. Major modes of transmission are still unclear. Oral-oral and fecal-oral routes are possibilities. There is also considerable evidence that H. pylori is transmitted between spouses. In Canada, the majority of H. pylori infections are acquired before the age of five years and that infection after that age is uncommon, less than one percent per year.

Who should be treated?

“Eradication therapy for patients with H. pylori infection who do not have underlying peptic ulcer disease has generally not been advocated,” says Alberta Clinical Practice Guidelines administered by the Alberta Medical Association. Two types of antibiotics and an acid suppressing drug like losec should be given for seven days to patients who have a proven peptic ulcer. Eradication rates are approximately 90 percent. Side effects of medications occur in less than five percent of patients.

Would I get it again?

True reinfection within one year is generally uncommon unless the initial management or compliance was poor. Late reoccurrence is caused by repeated exposure through contact with an infected partner.

So, Mr. Bugged, I hope this information helps to debug your stomach!

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