Medical Articles by Dr. Ray

Nov

2003

Stroke Risk Increases With Carotid Artery Disease

By Ray Schilling | Heart Disease, Prevention, Stroke

An important study about the risk of strokes and mini-strokes (called”transient ischemic attacks”) was published in the Oct. 27 edition of the Archives of Internal Medicine. Dr. Daniel J. Bertges and his group followed 1,004 patients between 1988 and 1997 with ultrasound studies of the carotid arteries (carotid artery duplex ultrasound scans). The studies took place at the Pittsburgh Veterans Affairs Medical Center/University of Pittsburgh School of Medicine. Patients were followed with regard to events such as strokes on the side of where the narrowed carotid artery was.

Reversible mini-strokes (medically correct term:”transient ischemic attack” or TIA) were also registered. A total of 1,701 narrowed arteries (called “stenotic arteries”) were found with this ultrasound method. All of the patients initially had no symptoms of the carotid artery stenosis (no dizziness, no fainting, no absence spells or symptoms of TIA or stroke). In 75% of the patients the carotid stenotic lesions were less than 50% meaning that the carotid artery blood flow was acceptable.

Here are some of the risks as the study went on over the years: both TIA and CVA risk in a given patient occurred at a rate of 3.3% per year. Regarding a specific involved artery the risk of developing a TIA as a result of this was 2% per year and the risk to develop a stroke was 2.1% per year. The investigators found that two main factors determined the ultimate progression into a TIA or a stroke and they were as follows. First, if the artery was severely stenosed at the outset, the probability was high that this would progress and be the cause of a stroke. Secondly, the degree of progression when checked with a follow-up duplex ultrasound was another important factor in terms of leading to a subsequent TIA or stroke.

Stroke Risk Increases With Carotid Artery Disease

Carotid artery clot can cause stroke

The composite risk of developing either a TIA or a stroke with a worsening stenotic carotid artery lesion was 1.68-fold. To develop a stroke alone in this scenario the risk was 1.78-fold. Clinical risk factors were of no help in predicting which cases would go on to develop TIA’s or strokes. However, the finding of further progression of a stenotic carotid artery lesion documented on serial duplex ultrasound studies was highly significant.

The authors concluded that there is value in doing serial carotid artery duplex scan studies in the same patient to screen for progressing stenotic lesions in the carotid arteries. When a stenotic lesion is significant enough or progressing fast, intervention by a cardiovascular surgeon with carotid endarterectomy can be done to prevent a stroke or TIA.

Here is a link to a chapter on strokes from the Net Health Book.

Last edited October 26, 2014

Nov

2003

Leeches And Arthritis Pain; Old Facts And New Insights

By Ray Schilling | Arthritis

Leeches have been used for centuries, particularly in Europe, for the treatment of chronic conditions and for arthritis pain. A group of researchers under Dr. Gustav J. Dobos from the University of Essen (Kliniken Essen-Mitte) in Germany published a paper in the Nov. 4, 2003 edition of the Annals of Internal Medicine (Ann Intern Med 2003;139:724-730,781-783) about the use of leeches in osteoarthritis, and particularly with knee arthritis.

In a randomized trial that lasted 91 days the researchers applied 4 to 6 leeches once to the knees of one group of 24 patients and used conventional diclofenac gel topical applications twice daily in a matched control group. On average the leeches fell off after 70 minutes. A simple pain score (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) visual analog scale pain scores) was used to quantitate the pain that the patients experienced in both groups. I have tabulated the results after 7 days of therapy and included the relative improvement in the pain score here, based on their data.

Leeches And Arthritis Pain; Old Facts And New Insights

According to Dr. Dobos there are powerful anti-inflammatories and hyaluronidase in the saliva of the leeches that have not been defined further. Now that these initial investigations have shown a more than 3-fold beneficial effect of the leeches versus conventional anti-inflammatory therapy for osteoarthritis, it is the intention of the group to define the active pharmaceutical ingredient from the leeches further.

Relief from osteoarthritis knee pain using leeches or diclofenac
Arthritis therapy:	WOMAC pain scores improved…	Relative improvement of pain score:
leeches (applied once)	from 19 to 52	64%
diclofenac gel (twice per day for 28 days)	from 42 to 52	19%

Apart from pain control other beneficial effects such as improvements in ranges of motion, swelling and inflammation were also noted, again more so in the group treated with leeches. However, leeches have the disadvantage that they puncture the skin and that they can transmit infections (from Aeromonas hydrophila). It is hoped that in future medication can be developed from this line of work that can be taken in pill form without the dangers of applying leeches.

Here is a link to a review of osteoarthritis from the Net Health Book.

Last edited October 26, 2014

Nov

2003

Blood Clots In Legs Can Be Caused From Long Flights

By Ray Schilling | Health, Lung Disease, Prevention, Uncategorized

A new study from Australia has shown that the risk for developing blood clots in the legs (deep vein thrombosis) is increased 4-fold in the first two weeks after a long-haul airplane flight. This was published on Nov. 8, 2003 in the British Medical Journal (BMJ. 2003;327:1072) with the lead author being Dr. C.W. Kelman of the Commonwealth Department of Health and Ageing, Canberra.

Data was collected of 5,408 patients who had been hospitalized to Western Australian hospitals for deep vein thrombosis between 1981 and 1999. A total of 153 Australians were admitted with blood clots in the leg veins within 100 days of international flights. 46 of these patients developed their blood clots within 14 days of arrival, which was much more than would have been expected in the general population. The researchers found that between 15 days and 100 days following a long-haul flight the risk of developing clots in the deep veins of the legs was not increased from the background rate of the general population. The patients who had developed their blood clots within 14 days of a long flight had a risk that was 4.17-fold higher than the average population’s risk. Of these patients 76% were thought to have developed the clots as a result of a flight. In terms of a yearly risk, if a person does one long-haul flight per year, the probability of developing a clot in the leg veins would be about 12% higher than in a non-traveling comparison group. As this condition is treated effectively with blood thinners, the death rate is quite low, approximately 1 per 2 million long-haul flights.

Blood Clots In Legs Can Be Caused From Long Flights

This would be much lower than the risk of death from car accidents. The authors suggested that more study is needed to determine the risk factors for developing flight induced deep vein thrombosis. When this is known, investigations will be able to concentrate on blood clot prevention from air travel.

Link to a chapter on pulmonary emboli, which can develop from a deep vein thrombus that breaks loose.

Last edited December 9, 2012

Nov

2003

Osteoporosis In Males Is Common

By Ray Schilling | Fitness, Health, Hormones, Prevention, Vitamins and supplements

A new study from the University of Toronto/Ontario has shown that contrary to the conventional teaching ostoporosis is not only a problem in females, but also a problem in males. The Canadian Multicentre Osteoporosis Study (CaMos) showed according to the epidemiologist Natalia Diaz-Granados that in Canada 16% of all women above the age of 50 and 5% of men above the age of 50 developed osteoporosis.

In the past men were thought to be more or less immune to osteoporosis, but this is not so. The results of this study were presented recently at the annual meeting of the American Society for Bone and Mineral Research in Minneapolis. 1,768 of the 2,884 men who were recruited into CaMos were eligible for the study, because they had not taken oral corticosteroids for three months, and bone scans were taken to measure bone density of their upper femurs (upper thigh bones). 89 men (or 5% of the group of 1768) showed osteoporosis. The mean age of this group was 65 years ranging from 50 to 96.

The researchers studied the high risk factors in men with osteoporosis and found that they were remarkably similar to the risk factors in women with osteoporosis. I have summarized the findings here in tabular form.
The study also showed that for men hip fractures seem to be more lethal than for women as within a year after a hip fracture from osteoporosis more men die. If a physician sees a patient and notices 2 or more of the risk factors identified in the table above, a bone scan to screen for osteoporosis should be done.

Osteoporosis In Males Is Common

There are many more unanswered questions with regard to life styles and nutritional information. It is not known from this study whether the men were physically less active and whether there was a higher alcohol abuse and /or nutritional dysbalance with associated vitamin deficiencies. The authors stated that future research will focus on these factors and on whether biphosphonates (alendronate or Fosamax) are as useful in men with osteoporosis as they are in women.

Risk factors for osteoporosis in men
Risk factor:	Explanation:
weight less than normal	this may point to poor nutrition, lack of calcium, vit. D etc.
older men	bone loss occurs slowly with age, both in men and women
history of smoking	smoking reduces blood supply to the nutritional vessels in the bone. This leads to less bone forming cells (osteoblasts)
family history of osteoporosis	one or more genes code for osteoporosis. More research needed in this field to develop new medications
history of fracture beyond the age of 50	osteoporosis leads to brittle bones with more fractures. A fracture in this age group should make the physician suspicious of osteoporosis or a metabolic bone problem

Based on an article in The Medical Post, page 78, Oct. 14, 2003.

Link to a chapter of osteoporosis in my Net Health Book.

Last edited December 9, 2012

Oct

2003

Flu Shot Cuts Death Rate Into Half

By Ray Schilling | Infectious Disease, Lung Disease, Prevention

An earlier publication in the New England Journal of Medicine in March 2003 has shown that the death rate of people 65 years or older who were vaccinated against the flu, dropped into half when they were exposed to the flu and were compared to non-vaccinated controls. On Oct. 9, 2003 Dr. Megan Wren, associate director of the internal medicine residency at Barnes-Jewish Hospital and Washington University School of Medicine, reminded physicians that with the upcoming flu season it is important to include everybody who is healthy at age 50 or older (as the CDC has suggested now for 3 years) with influenza vaccination . Many physicians are still not aware that the rules have been changed to incude younger persons.

Below are recommendations of who should get a vaccination (in table form).

Dr. Wren pointed out that the risk from a flu vaccination is minimal. Contrary to public belief the flu vaccine does not cause fever, unwellness or muscle aches. The only effect is a mildly sore arm at the site of injection.

Flu Shot Cuts Death Rate Into Half

This year the FDA has approved a live flu vaccine that is administered as a nasal spray. This is a live modified flu virus that has been “trained” to only multiply in the colder nasal cavity, but not in the warmer airways. Like with all live viral vaccines pregnant women are not allowed to take this.

Who should get the flu vaccine ?
Group of people:	Comments:
all people age 50 or over	the immune system weakens with age, that’s why complications of the flu are more common in this age group
women who will be in the 2nd or 3rd trimester of a pregnancy during November through to March	protects the fetus from the flu virus in the most vulnerable period of the development of the fetus
chronic heart disease or lung disease (including asthma)	the flu affects the lungs and the heart most readily
chronic kidney or liver disease	these chronic diseases weaken the immune system
people without a spleen and cancer patients	the immune system is weak in these patients
children and adults with any chronic disease including diabetes	chronic illnesses weaken the immune system in young and old
people on imunosuppressive medications	the immune system is weak in these patients
all close family members of any of the above people	the CDC hopes that this stops the spread of the flu into this vulnerable group of patients

Dr. Wren also mentioned that people with chronic illnesses, with immune deficiencies (e.g. AIDS and cancer patients) and healthy patients over the age of 50 cannot take this live vaccine. All others from age 5 to 49 can take it, but presently this is still very costly (one nasal mist application in 2003 is about 50.00$ US).

Last edited December 9, 2012

Oct

2003

Ozone And Pollution Linked To Asthma

By Ray Schilling | Lung Disease

Ozone and pollutants were the topics of two independent publications in October 2003, one in the New England Journal of Medicine (N Engl J Med) and the other in the Journal of the American Medical Association (JAMA).

Dr. Janneane F. Gent of Yale University School of Medicine in New Haven, Connecticut, and her team studied the effects of ozone and small pollutant particles on 271 cases of asthma in children less than 12 years of age (results published in the Oct. 8 ,2003 issue of JAMA). The researchers asked the question whether the air standards of the Environmental Protection Agency would be safe for asthmatic children. From spring 2001until now (about 2 years) exposure of air pollution was measured.

They found that in terms of particulate matter in the air the minimum standards were acceptable and no worsening of asthma took place because of flucutations in this component of air pollution (fine particulate matter of 2.5 micrometers or less). However, exposure to fluctuating ozone levels considered sofar to be safe were found to have profound effects in terms of worsening the asthma in the group of children being followed. For every 50 parts per billion (ppb) increase (in one hour ozone level) the wheezing of these astmatic children increased by 35% and chest tightness increased by 47%. At the time of the highest ozone exposure from a bad day of pollution, which was still “acceptable” to the standards of the Environmental Protection Agency, there was a 32% increase in shortness of breath and the children had to increase their medications by an average of 8% to cope with their asthma attacks (based on JAMA 2003;290:1859-1867,1915-1916).

Asthma made worse by pollution

A different facet of the asthma problem was dealt with in the Oct. 9, 2003 issue of the New England Journal of Medicine. Dr. Malcolm R. Sears from the McMaster University in Hamilton/Canada reported about a group of 613 children born in Dunedin/New Zealand in 1972 and 1973 who were followed with breathing tests and questionnaires until they reached the age of 26 years. This study showed that it does matter very much what lung irritants the very young asthmatic was exposed to and what lung irritants continue to affect the person later in life.

About half of the study population had at least one wheezing attack during the 26 years of observation. Contrary to popular belief asthma is not something “you grow out of” with age as 26.9% either had wheezing that persisited all the time (14.5%) or where the wheezing came back in adult life(12.4%). Allergies to house dust were associated with a risk of more than double and general airway hypersensitivity was associated with a triple risk of causing wheezing persistence or causing a return to wheezing. Other factors that were contributing to risk were female gender (1.7-fold risk) and exposure to cigarette smoke (1.8-fold risk). Those who started smoking young had the highest risk of asthma persistence and severity.

The more wheezing attacks there were and the more persistent the asthma was, the more permanently abnormal the lung function tests remained. The authors concluded that intervention against factors that lead to asthma must be initiated at a very young age. It is crucial to not allow environmental factors (ozone, pollution, allergens, cigarette smoke etc.) to interact with the asthma gene as this will lead to the more severe and chronic forms of asthma with permently abnormal lung function.

These two studies would reconfirm what the recent Swedish family lifestyle study had found as well. All of these studies point to the importance of the air quality and how the environment affects not only those with asthma, but affects everybody. Asthmatics simply are the tip of the iceberg due to a genetic weakness with which they were born. This makes asthmatics particularly vulnerable to pollution and to other environmental factors.

Link to a chapter on asthma from Dr. Schilling’s Net Health Book.

Last edited October 26, 2014

Oct

2003

Schizophrenia Gene Discovered

By Ray Schilling | Mental Health

In the not too distant future new tests and new anti-psychotic drugs (“designer drugs” rather than “trial and error drugs”) for schizophrenia will likely be developed in the US because of the following new findings.

At the 19th International Congress of Genetics in Melbourne/Australia (July 2003) the Nobel Prize laureate Dr. Susumu Tonegawa, who had won the 1987 Nobel Prize for Medicine, reported about his new discovery of a gene that controls schizophrenia. This has already been studied extensively in mice by the research team that he is heading (from the Howard Hughes Medical Institute of Technology (MIT) in Cambridge/Mass).

Together with other colleagues from other Centers (Duke University, Rockefeller University and Columbia University College of Physicians and Surgeons) they have developed an animal model, a “schizophrenic mouse”, that is defective for the schizophrenia gene. Researchers had found that an enzyme called “calcineurin” was missing in schizophrenic families where genetic defects could be located in one particular gene. Subsequently this type of gene was also shown to be important for the normal brain metabolism in mice. The detection of a mouse model for schizophrenia has made it much easier to do ground-breaking research in the field of schizophrenia. Dr. Tonegawa said that the existing drugs for schizophrenia were developed by trial and error. In some patients these drugs do not work, in many others they have serious side-effects. He stated further that in future there will be a new class of anti-psychotic drugs with minimal side-effects as they will specifically normalize the calcineurin production.

Anti-psychotic designer drugs

This in turn will normalize the derailed brain metabolism. In schizophrenics it is in this area where the psychotic behavior originates due to a lack of normal calcineurin production. This enzyme is found not only in brain tissue, but also in immune cells such as the T lymphocytes throughout the body. Because of this connection a future modern treatment for schizophrenia will likely normalize the brain metabolism, but also have beneficial effects on the entire immune system.

Here is a link to a review of schizophrenic disorders

Last edited October 26, 2014

Oct

2003

Heart Scan Saves Lives In Diabetics

By Ray Schilling | Diabetes, Heart Disease, Prevention

A simple new nuclear perfusion study of the heart when applied to healthy appearing diabetics (adult onset or “type 2 diabetics”) showed silent hardening of the coronary arteries in 21.6%. This large study of an American medical team was recently presented at the 18th Congress of the International Diabetes Federation in Paris/France. Dr. F. Wackers, professor of medicine from Yale University school of medicine and one of the lead investigators, explained that 1,124 patients with diabetes in the age range of 55 to 75 years who were all thought to not have any heart blood vessel disease, either had nuclear perfusion studies performed and a control group did not.

As indicated above to the surprise of the investigators 113 patients of 522 (=21.6%) had positive heart scans showing perfusion difficulties of the heart muscle. Further testing with other methods revealed that 73% indeed had perfusion defects and 27% had other heart disease, electrocardiogram abnormalities and other heart dysfunctions. Conventional assessment tools such as a smoking history, determination of degree of obesity, blood pressure,kidney disease , high blood lipid levels, high C-reactive protein levels, the diabetes test hemoglobin A1C or homocysteine levels in the blood were also assessed. However, these conventional tests did not help in predicting that these patients would have developed perfusion defects in their heart muscle. This was due to hidden narrowing of the heart blood vessels (=coronary arteries) and this affected the supply of nutrients and oxygen to the heart even though these patients were completely symptom free at the beginning of the trial.

Heart vessels and nuclear scan

Dr. Vivian Fonsega, a professor of medicine and pharmacology at Tulane University in New Orleans and co-researcher of the team, added that after a follow-up of 1 year those who had normal initial nuclear perfusion studies of the heart only 1% developed serious heart disease. These control patients who have now been followed for 3 years overall remained very healthy. In other words a normal (called “negative”) nuclear perfusion test in diabetics predicts a better longterm outcome than a positive perfusion test.

With this heart scan the cardiologist can identfy the high risk group among diabetics and can subsequently concetrate on doing something actively about the identified diseased heart blood vessel(=”coronary artery”) disease. Identified narrowing in the coronary arteries (“stenotic arterial lesions”) can be overcome by prying them open and placing heart stents across the affected section utilizing catheters (angiography). In other cases heart bypass surgery can be done by the heart surgeon to improve the perfusion of the heart muscle. The researchers stressed that those diabetics at risk can be identified with this test and the life expectancy of this high risk group of patients can be significantly prolonged. The study will continue for several more years so that the longterm results of any intervention can be measured when compared to controls.

Based on The Medical Post (Sept. 23, 2003 ): p. 55.

Here is a link to a chapter on diabetes and here is a link to heart attacks.

Last edited December 9, 2012

Oct

2003

Better Recovery From Strokes Through Early CT Scans

By Ray Schilling | Other neurological conditions, Stroke

Introduction

You can have a better recovery from strokes through early CT scans. This was published in the September 2001 issue of the American Journal of Neuroradiology (Am J Neuroradiol – 01-SEP-2001; 22(8): 1534-42). A group of clinicians from the Foothills Hospital in Calgary/Alberta published an article with a scoring system for CT scans. These scans were done on every patient with a stroke. By utilizing early CT scans and this scoring system an ischemic stroke (due to a blood vessel that closed off in the brain) could be rapidly assessed.

Early CT scan helps to decide whether clot-busting drugs help the patient

Within 3 hours of the beginning of the stroke the treating physician would know whether the patient would benefit from clot-busting drugs (TPA or tissue plasminogen activator) or not. Dr. Pexman and co-workers had noted that patients with an Alberta Stroke Program Early CT Score (ASPECTS) of less than 7 had a poor survival rate or an outcome with high dependency on caregivers. Patients with a score of 7 to 10 had a much better survival chance and were ideal candidates for the clot-busting therapy. The radiologist who reads the CT scan of the brain of the stroke patient divides th CT scan into 10 regions. Researchers evaluate the findings systematically and obtain an ASPECTS score.

Ischemic strokes treated early

Dr. Michael Hill, an assistant professor at the University of Calgary, and one of the co-workers of this initial study has now completed a further follow-up study together with Dr. A.Buchan, director of the Calgary Stroke Program. The authors published the results of the study in the August 2003 issue of the medical journal “Stroke”. They found that ischemic strokes (from clots in the middle cerebral artery) have the best outcome when detected by CT scan early (within 3 hours of the beginning of the stroke) and if thrombolysis therapy with TPA, the clot-busting drug, is done before 6 hours after the beginning of the stroke.

Better Recovery From Strokes Through Early CAT Scans

CT Scan of Ischemic Stroke

Stroke in the middle cerebral artery diagnosed early

The lack of blood circulation from a stroke, which closed the middle cerebral artery, is shown in this link. What does that mean in practical terms? Let us assume a patient is suddenly losing all of the strength and movement in one arm and losing speech as well. In this case the physician orders an emergency CT scan right away. This helps to determine that the patient had a stroke in the middle cerebral artery region. Let us say that the ASPECTS score was between 7 and 10. This patient’s physicians would likely treat the stroke with the clot-busting medicine mentioned being confident that there likely will be a good outcome.

Less permanent palsies with early intervention

Before this therapy was available, many of these patients ended up with a permanent arm palsy without much function. They likely also sustained a permanent speech deficit as well. After the clot-busting therapy many of these patients have a much better outlook. Now they have a considerably better return of function in their arm and regain their speech as well. Unfortunately, the opposite is true as well.

Those with an ASPECTS score below 7 do poorly with their stroke

Those with a poor ASPECTS score below 7 will not be candidates for the clot-busting therapy. They tend to do poorly. Several countries use this scoring system of early CT scans already to investigate the severity of strokes (ASPECTS). Among those are Canada, the US, Australia and Europe. Dr. A.Buchan said: “Early detection and intervention in stroke is critical to achieve a positive outcome”. He is the director of the Calgary Stroke Program. In addition, he is also a professor in the department of clinical neurosciences of the University of Calgary/Alberta. Here is a link for more background on strokes.

Sep

2003

West Nile Virus (WNV) Vaccine Being Tested In Humans

By Ray Schilling | Infectious Disease, Prevention

According to Dr. Tom Monath, the scientific officer of the Acambis pharmaceutical company, human trials on a new vaccine for West Nile virus (WNV) can begin as soon as the FDA will give the green light (likely in October of 2003).

At the 2003 World Vaccine Conference in Montreal/Canada this summer Dr. Monath explained that Acambis has been doing research for a new vaccine against WNV since 1999 when this virus arrived in New York. The virus belongs into the same group of flaviviruses as dengue fever, yellow fever and Japanese encephalitis.

Yellow fever has been successfully prevented by vaccination with a live vaccine that has been modified considerably (called 17D attenuated vaccine). This strain is basically a harmless virus, which will induce a strong immune response in 100% of vaccinated people. If this is repeated every 10 years, a vaccinated person would be safe to travel in yellow fever infested areas. Based on this knowledge the researchers of Acambis have created a chimera virus where the yellow fever vaccine (attenuated virus 17D) is used as a vehicle in the center while the surface has been modified by incorporating parts of the WNV into its envelope. As this new vaccine virus has qualities of both the yellow fever vaccine virus and the WNV, it is called a chimera virus. The same technology has already been successfully applied to two other flavivirus vaccines, namely the dengue fever vaccine and the Japanese encephalitis vaccine.

West Nile Virus (WNV) Vaccine Being Tested In Humans

The new WNV vaccine has been tested extensively in mice and monkeys and has been found sofar to be very safe and it is mounting a very good immune response. It is timely that human trials are being done now starting this fall as WNV seems to be expanding rapidly throughout the United States and Canada. The vaccine would be needed particularly for older people as in them the WNV disease presents much more violently with a higher death rate. However, visitors from Europe to the US and Canada will likely want to protect themselves as well before they travel.

Comment in July 2012: A vaccine for humans is still not available, for horses it is.

Last edited December 9, 2012

Who should get the flu vaccine ?

Group of people:

Comments:

Introduction

Early CT scan helps to decide whether clot-busting drugs help the patient

Ischemic strokes treated early

Stroke in the middle cerebral artery diagnosed early

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