Time Is Of the Essence in Acute Stroke Treatment

Ambulance at Emergency EntranceWe are fortunate to live in an area where several of the local hospitals including Boca Raton Regional Hospital and Delray Medical Center are certified stroke treatment facilities. What this means is that if you are experiencing symptoms of a sudden and acute stroke then they are prepared to begin lifesaving and permanent neurological damage sparing treatment within 60 minutes of arrival on site. This means we need to transport you to the facility quickly and efficiently if the signs of a stroke occur. Ideally we wish to begin treatment within three hours of the onset of the symptoms if possible, but under some circumstances we can extend that to six hours. At these facilities they have the staff and training to rapidly assess your neurological status and cardiovascular status, perform the necessary imaging studies of the brain and cerebral blood vessels and start you on a thrombolytic medication such as rtPA quickly and safely to save your life and or prevent severe permanent neurological damage.

Our local hospitals have recently reminded their physician and nursing staff of the different options available for stroke management. They all require the same thing. Patients and their loved ones must rapidly recognize the symptoms of an evolving stroke and seek medical attention by calling 911 and being transported to a stroke center. If you or your loved one suddenly develops a drooping face it is time to call 911. Ask the person to smile and if one side droops then the problem needs immediate investigation. If the individual develops sudden weakness in an arm or leg, especially if they are on the same side of the body then you need to call 911 immediately. If the person suddenly develops difficulty speaking it is time to call 911. That would include problems with finding the correct words or just pronouncing the words correctly in a manner that is not garbled. If the patient suddenly develops problems seeing out of one or both eyes or part of one or both eyes it is time for an immediate evaluation. The same can be said for the sudden onset of confusion in an individual who never had this problem. Call 911. We additionally recommend immediate evaluation for sudden dizziness, loss of balance or loss or coordination.

After 911 has been called you may then call your doctor or family to inform them. If you have an aspirin you may administer it. If you have a list of the patient’s medications bring it or the pills in the original pill bottles. Getting to a stroke center quickly may save your life or save you from permanent neurological damage.

Coffee Consumption May Lead to Safer Driving Trips

CoffeeIt is no secret that for decades men and women have been drinking caffeinated beverages to wake up or stay awake. This is especially pertinent when it comes to driving an auto or a truck and trying to stay alert and awake. Researchers in Australia decided to take a look at the question of whether ingesting caffeine in the form coffee or tea led to fewer accidents. Lisa Sharwood, PhD, of the University of Sydney reported in the British Medical Journal that long haul truckers who reported consuming caffeine to stay awake had a 63% reduced likelihood of crashing than control subjects. Their study looked at 530 long-haul truck drivers who had an accident between December 2008 and May 2011 in Australia. They compared them to 517 controls that had no accidents in the same 12 month period.

Case drivers drove about 1,700 miles in the week before their accident. Controls drove somewhat more, about 2,400 miles, in the week before their interview. 43% of the case drivers admitted to drinking caffeinated beverages specifically to stay awake. Only 3% admitted using illegal substances such as amphetamines or cocaine to stay awake.

The practical side of the study is that if you must operate a motor vehicle and you feel fatigued then stopping for a caffeine containing beverage definitely helps reduce the likelihood of a crash.

Benefits of Smoking Cessation Outweigh Negatives of Weight Gain

A196HJ Woman smoking a cigarette Exhaling tobacco smokeIf you wish to extend your life and stay healthy then giving up smoking tobacco is a major positive step. The benefits include an immediate drop in your cardiovascular disease risk profile, a drop in the possibility of developing numerous types of cancer and a decrease in the likelihood of developing chronic obstructive lung disease.

Smoking is an expensive, dirty habit that not only sickens you but exposes those around you to an increased chance of disease due to others breathing in your second hand smoke. Asthma in children is now believed to be related to the children’s exposure to their parents’ second hand smoke. One of the negatives of stopping smoking is that individuals tend to put on weight. Weight gain and obesity are known risk factors for the development of heart disease and vascular disease.

In the March 13th issue of the Journal of the American Medical Association (JAMA), Carole Clair, MD, of the University of Lausanne in Switzerland examined the question of whether the weight gain was detrimental to your heart health. She accessed data from the famed and long term Framingham Offspring Study looking at the years 1984 through 2011 for 3251 study participants who were free of cardiovascular disease at the start of the analysis. These participants underwent a checkup every four years and were placed into categories such as “recent quitter” (stopped smoking within 4 years),” long term quitter” (nonsmoker for > 4 years) and nonsmoker.

As anticipated, smoking cessation was associated with a weight gain of 5.9 lbs. in the recent quitters and 1.9 lbs. in the long term quitters. Smokers also gained weight during the study period while the country underwent and obesity epidemic. Smokers gained an average of 1.9 lbs. while nonsmokers gained about 3 lbs.

They followed these people for 25 years and defined 631 “cardiovascular events.” In reviewing the data they concluded that former smokers had about one half the risk of developing cardiovascular disease as smokers. When they factored in the weight gain associated with smoking cessation it had no effect on the reduction in cardiovascular disease.

They concluded that the findings support, “a net cardiovascular benefit of smoking cessation, despite subsequent weight gain.” The goal is clear. Stop smoking and then we will work on the weight gain.

No CPR Policy at California Independent Living Facility

Young Man Doing Chest Compressions on Elderly ManLast month, an 87 year old resident of a California senior living facility dropped to the floor suddenly with no spontaneous respirations or heart beats. A nurse on duty immediately called 911 to summon medical assistance. The 911 operator instructed the nurse to begin cardiopulmonary resuscitation. The nurse refused stating that the facility had a policy of calling for help but not providing any medical help. The 911 operator begged the nurse to begin CPR or at least call another resident or worker to begin the CPR policy. She refused per institutional policy. When the paramedics arrived a few minutes later, the 87 year old was clinically dead.

The facility took the position that its residents or their health care surrogates knew of the “NO CPR” policy in advance and were comfortable with it. The family of the woman said they were aware of the no CPR policy in advance and were comfortable with the care and compassion the patient had received while a resident. The incident caused a national furor and outcry over the “NO CPR” policy.

In the State of Florida, those residents requesting a NO CPR or Do Not Resuscitate status need to fill out and display the yellow Do Not Resuscitate form # 1896. It is a two-part form. The larger part should be displayed prominently in one’s home, usually on the refrigerator. The smaller copy should be placed in one’s wallet and be available at all times. Your doctor will be required to sign both forms. Your physician should be given a copy for their records as well.

When you enter a hospital electively or emergently you will need to inform the staff that you have a State of Florida DNR form #1896 and they will make a copy and place it on your medical record chart. You may rescind this order and request full resuscitation status if you so desire at any time!

 

It is important before you enter or contract with a senior facility to live there that you learn what their policy is for providing all types of care. You will need to agree with the policy or you should choose to live elsewhere.

Cervical Cancer Screening Guidelines – American College of Obstetricians and Gynecologists

Cervical Cancer Screening - Steve Reznick, M.D.On a routine basis my female patients, many of whom have undergone a total hysterectomy, ask me if they need to continue to have Pap smears annually. There has clearly been a great deal of confusion about who should get a Pap smears and when. This communication is an attempt to clear that up.

1. Women who have had a hysterectomy and removal of the cervix (total hysterectomy) and; have never had an abnormal Pap smear (graded a CIN 2 or higher – cervical intraepithelial neoplasia), do not require a Pap smear. If they are still getting them they should be discontinued and never restarted

2. Screening for cervical cancer by any modality should be discontinued after age 65 years in women with evidence of adequate negative prior screening ( 3 consecutive negativ pap smears with the most recent having been done within 5 years and no history of abnormal Pap smears graded CIN 2 or higher).

3. Cervical cancer screening should begin at age 21 years. Women younger than 21 years should not be screened regardless of the age of initiation of sexual activity or the presence of other behavior related risk factors.

4. Women aged 21-29 years should be tested with cervical cytology alone. Screening should be performed every 3 years

5. Women aged 30-65 should have “co testing with cytology and human papillomavirus (HPV) testing every 5 years.

6. In women aged 30-65 years, screening with Pal smear cytology every 3 years is acceptable. Annual screening is not preferred.

7. Women who have a history of cervical cancer, have HIV infection, are immunocompromised, or were exposed to diethylstilbestrol in utero should not follow these minimal routine screening guidelines.

8. Both liquid-based and conventional methods of cervical cytology collection are acceptable for screening.

ACE Inhibitors Linked to Hallucinations In The Elderly

????????????????John Doane, MD, and Barry Stults, MD, from the University of Utah Health Science Center in Salt Lake City reported in the Journal of Clinical Hypertension on four cases of visual hallucinations in elderly patients taking the drug lisinopril for blood pressure control. ACE inhibitors are a popular and relatively safe drug. They are used for blood pressure control especially in diabetics.

The patients’ adverse effect profile has been limited to a dry allergic cough, elevated potassium, rash, angioedema and renal insufficiency.   They ranged in age from 92-101 and were being treated for hypertension or heart failure. Two had mild cognitive impairment, one had Alzheimer’s disease and one had vascular dementia. The time from beginning the drugs until hallucinations appeared varied from two months to six years. In each case when the drug was stopped the hallucinations resolved. In one case the patient was re-challenged with lisinopril and the hallucinations returned.

The authors conducted a thorough literature search and found several other reports of ACE inhibitor related hallucinations. In each case the hallucinations resolved when the drug was discontinued. It is believed that ACE inhibitors raise the level of opioid peptides causing these hallucinations. While the side effect is rare, it is certainly worth knowing about as the population ages and clinicians are looking for safe drugs to treat high blood pressure and heart failure.