stroke

RECENT POSTS

Hillary Clinton’s Clots, Or How Blood Thinners Could Affect Presidency

Former Secretary of State Hillary Rodham Clinton walks past the Presidential seal in the East Room of the White House in Washington, Nov. 20, 2013. (AP Photo/Jacquelyn Martin)

Former Secretary of State Hillary Rodham Clinton walks past the Presidential seal in the East Room of the White House in Washington, Nov. 20, 2013. (AP Photo/Jacquelyn Martin)

There’s nothing like a famous public figure to illustrate a medical lesson, as our friends over at Celebrity Diagnosis well know. But a new post on HealthNewsReview.org — a widely respected health journalism watchdog site — brings that art to new heights. You may not normally be interested in inside-baseball medical battles about how widely used blood thinners like Coumadin should be prescribed, but does this get your attention?

“…if Clinton takes a VKA [Vitamin K antagonist like Coumadin] or other oral anticoagulant continuously over the next 11 ¼ years (i.e., throughout 2 more Presidential election terms should she win in 2016 and 2020), her cumulative risk of fatal bleeding, would be about 55% (1 – 0.994^135 months). Even if she had only the all ages risk of major and fatal bleeding over the next 11 ¼ years (major bleeding: 0.29%/patient-month and fatal bleeding: 0.09%/patient-month), her risk of catastrophic bleeding before 2025 would be considerable (major bleeding: 32% (1 – 0.9971^135 months) and fatal bleeding: 12% (1 – 0.9991^135 months).

The post’s author, Dr. David K. Cundiff, argues that the current guidelines for prescribing Coumadin and other anticoagulants are skewed too heavily in favor of prescribing the drugs, despite the harms they may cause. He writes that the guidelines’ evidence base is weak, and possibly biased by financial conflicts of interest, and that we need to improve the process for setting such hugely influential guidelines.

Read the full post here for his cogent policy points, but I must confess that what stuck in my mind was his take on Hillary Clinton’s public medical record and how it could affect the next presidential campaign: Continue reading

WSJ: Everything You Need To Know About New Cholesterol Guidelines

It’s so very disconcerting when deeply entrenched health wisdom is suddenly flipped on its head. But that’s the way it often goes in this arena.

The Comedian/flickr

The Comedian/flickr

So, with such widespread confusion over the new guidelines on cholesterol and statins, cholesterol-lowering drugs, I was relieved to see that veteran health reporter (and my former colleague) Ron Winslow at The Wall Street Journal offered a just-the-facts-ma’am Q & A on exactly what you need to know about the new guidelines. It’s got everything from LDLs to the new risk calculator — which was down when I checked this morning. (What’s going on with all the bugs in our critcal health care sites??)

Here’s a snippet from Winslow:

The new tack recommended by the American Heart Association and the American College of Cardiology is to prescribe moderate to high doses of cholesterol-lowering drugs called statins to patients who fall into one of four risk groups regardless of their LDL status. Here is a look at the implications:

Q. Why get rid of the LDL targets?

A. The targets lack strong scientific evidence. The expert panel that developed the guidelines concluded that by focusing on an individual patient’s overall risk rather than a relatively arbitrary set of LDL targets, the strategy to prevent heart attacks and strokes will be more effective and more personally tailored to the needs and preferences of each patient.

Q. What should patients do in response?

A. Patients already on cholesterol-lowering medication should ask their doctors at their next appointment whether they are on the most appropriate therapy to reduce their heart-attack and stroke risk, says Neil Stone, a cardiologist at Northwestern University who headed the panel that wrote the cholesterol guideline.

For people not on cholesterol drugs, a new risk calculator is available online. If you have a 7.5% chance of having a heart attack over the next 10 years, you are a candidate for treatment with a statin no matter your LDL level under the new guidelines.

Q. I have no heart problems and my LDL was 90 in a recent cholesterol test. Is it possible I should be on a statin anyway? Continue reading

Why To Exercise Today: It’s As Good As (Or Better Than) Drugs

In my house, there’s a little sticker over the sink that says: “Exercise before showering!”

exercisebeforeshowering

We don’t always abide by that, but we always aspire to it.

And here’s yet another rational analysis to back us up: new research published in the BMJ concludes that physical activity looks to be as effective as many drugs for patients with existing heart disease or stroke.

Exercise, say the study authors, “should be considered as a viable alternative to, or alongside, drug therapy.”

From the paper:

Although limited in quantity, existing randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

runner with inhaler (Matthew Kenwrick/Flickr)

(Matthew Kenwrick/Flickr)

Here’s more from the BMJ news release:

Physical activity has well documented health benefits, yet in the UK, only 14% of adults exercise regularly, with roughly one third of adults in England meeting recommended levels of physical activity. In contrast, prescription drug rates continue to skyrocket, sharply rising to an average of 17.7 prescriptions for every person in England in 2010, compared with 11.2 in 2000.

But there is very little evidence on how exercise compares with drugs in reducing the risk of death for common diseases.

So researchers based at the London School of Economics, Harvard Pilgrim Health Care Institute at Harvard Medical School and Stanford University School of Medicine set out to compare the effectiveness of exercise versus drugs on mortality across four conditions (secondary prevention of coronary heart disease, rehabilitation of stroke, treatment of heart failure and prevention of diabetes).

Secondary prevention refers to treating patients with existing disease before it causes significant illness.

They analysed the results of 305 randomised controlled trials involving 339,274 individuals and found no statistically detectable differences between exercise and drug interventions for secondary prevention of heart disease Continue reading

Why To Exercise Today: So You Don’t Have A Stroke

runner with inhaler (Matthew Kenwrick/Flickr)

(Matthew Kenwrick/Flickr)

Don’t use the heat as an excuse.  You can always climb stairs in an air-conditioned office building or run over to the gym. Or, if you’re lucky enough to be out of town, jump in the lake for a long, glorious, vigorous swim.

In any case, you should do something. According to new research, breaking a sweat while exercising regularly may reduce your risk of stroke. You’ve heard it before. But it’s worth restating. Why wouldn’t you run around a little a few times a week to possibly avoid the horrible physical ordeal of a stroke? Particularly if you live in a part of the country known for its high stroke rate? But enough nagging.

The new, NIH-funded study of more than 27,000 Americans, 45 years and older who were followed for an average of 5.7 years, was published today in the American Heart Association journal Stroke. Most participants, equally divided between men and women, black and white, lived in regions of the southeastern U.S., known as “the stroke belt.”

From the AHA news release:

  • One-third of participants reported being inactive, exercising less than once a week.
  • Inactive people were 20 percent more likely to experience a stroke or mini-stroke than those who exercised at moderate to vigorous intensity (enough to break a sweat) at least four times a week.
    Continue reading

Specialist: My Prime Take-Home Points From ‘Dot Earth’ Reporter’s Stroke

 

 

This week, longtime New York Times reporter and popular “Dot Earth” blogger Andrew Revkin vividly describes his 2011 stroke in the first-person piece “My Lucky Stroke.” He includes these “prime take-home points”: “Take your body seriously. Time (wasted) is brain (lost). Question authority, but not too much. Old habits die hard.”

Dr. Lee Schwamm, chief of Massachusetts General Hospital’s stroke service and medical director of Mass General TeleHealth, would suggest that readers take away some rather different stroke lessons from Andy Revkin’s story. He shares them here.

By Dr. Lee H. Schwamm
Guest contributor

I congratulate the journalist and blogger Andy Revkin for courageously sharing the story of his stroke and his subsequent recovery. I also thank him for taking the time to share his personal experience for the benefit of his readers, and for the opportunity it presents to highlight some key learning points for patients, as we dissect his journey through the health-care system.

Mr. Revkin was relatively young and healthy, out for a run with his son, when he experienced stroke symptoms. All too often, when we think of stroke, we envision an older patient clutching their chest and being unable to move or speak. This stereotype is dangerous, both for patients and health-care providers, because it lowers our sensitivity to stroke-like symptoms in patients of any age.

Mr. Revkin and his son were concerned enough about his symptoms that he went home, but they didn’t appreciate the immediate seriousness of his condition and he took a shower, hoping his symptoms would resolve. Watch the video clip above showing a young news reporter having stroke-like symptoms, and ask yourself, would you have called 911 if you’d been present? You should have.

Without treatment to restore the blocked blood flow to the brain, 2 million nerve cells are dying every minute of continued stroke.

Then Mr. Revkin did what generations of doctors have advised us to do for a heart attack; namely, take some aspirin and call your doctor’s office. Unfortunately, when it comes to stroke, there are two types: those caused by blocked arteries (ischemic) and those caused by rupture of blood vessels (hemorrhagic). It’s not possible to tell just from symptoms if a stroke is ischemic or hemorrhagic; only a CAT scan or MRI can distinguish them.

Obviously, you don’t want to take an aspirin if you’re having bleeding in your brain, as it will make the bleeding worse. But it’s also not a great idea to take aspirin if it’s an ischemic stroke, especially not six aspirin, as Mr. Revkin did, because there are powerful clot-busting drugs that can be given to reverse the disability caused by ischemic stroke. These drugs — the main one is known as tPA — are only effective if they are given within the first 4.5 hours after the start of symptoms, and aspirin might increase the risk that the drugs could convert an ischemic stroke into a giant hemorrhage that could be fatal.

It’s also really important to realize, as Mr. Revkin mentions, that “time is brain.” Continue reading

Three Recent Warnings On Antidepressants; Latest Is Stroke Risk


As we all know, three of anything makes a trend in journalism, and my trend alarm has just gone off concerning scary news about antidepressants. First, there was this review three weeks ago finding a “modest link” between antidepressants and cancer — though not in studies funded by the drug companies.

Then, author and former Globe staffer Alison Bass reported a week ago on her blog here that a researcher has found that serious flaws tended to skew the biggest study ever of antidepressants toward making the drugs appear more effective than they really are.

And now, Dr. Adam C. Urato, assistant professor of medicine at Tufts, has just sent over the latest: a paper in the current American Journal of Psychiatry that suggests that antidepressants increase the risk of stroke. He emailed:

This is an important study with real public health implications. We have so many patients on these drugs and use seems to be ever-increasing. If they are associated with stroke, as they seem to be, that’s information that patients and the public need to know.
When you combine this type of study showing a risk of stroke like this with the other studies that now show that antidepressants don’t appear to have a clinically significant benefit for most patients with mild to moderate depression (i.e. most users) then you really have to question why so many patients are on these drugs.

I leave it to others to defend antidepressants, but here are the basics on the latest study: It appears in the May edition of the American Journal of Psychiatry. It uses a “case-crossover” design, which aims to identify triggers for events. In this case, the event is a stroke. It included more than 24,000 patients who’d had strokes in Taiwan. The findings:

We found that antidepressant use was associated with a 48% greater risk of stroke, Continue reading

Must-Read: Harvard Business Guru’s Own Diabetes, Cancer, Stroke Shape His Views

http://www.youtube.com/watch?v=siE20W5fSoU

Forbes Magazine has just posted here a deeply personal, multi-faceted feature on Clayton Christensen, the renowned Harvard Business School professor and co-author of “The Innovator’s Prescription,” a 2009 book on what is wrong with the health care system and how to fix it.

The Forbes piece includes his own struggles with diabetes, cancer and a recent stroke, as well as the deep religious beliefs that permeate his life. Accordiing to Forbes writer David Whelan:

Christensen’s work took on new urgency the past few years as he suffered a heart attack followed by cancer followed by a stroke. For Christensen it was not a reason to get too upset. It was another opportunity, in a lifetime full of them, to gain insight into how to make the world work better. Because of his July stroke it took a long time for Christensen to be ready to sit down with FORBES. He was in intensive speech therapy, eight hours a day at the beginning. But he graciously agreed to tell his inspiring story in January, the same month he went back to teaching.

Special Report: Ten Halting Steps Forward In Research On Stroke

A stroke patient at Spaulding Rehabilitation Hospital

Stroke eventually killed my biological father, But first it turned him from a successful doctor, author and professor into a Job-like figure who lost everything he loved.

He and my mother split up before I was born, and he went on to a second stormy divorce. He had finally found happiness in his third marriage, to a woman seventeen years his junior. But his youthful wife broke under the pressure of caring for him in his diminished, post-stroke form. She slit her own throat with a razor. He found her in the bedroom in a welter of blood and saved her life, pinching her artery closed to stop the spurting until the paramedics arrived. After she recovered, she divorced him, despite all his entreaties. Living on her own, she tried again to bleed to death, and there was no one there to save her.

My father had loved being a doctor. The stroke knocked out just enough of his memory and reasoning faculties to make him clearly unfit to practice. He had loved writing medical novels. The stroke left him unable to spell even the simplest words, and plotting that had once been complex and suspenseful now came out embarrassingly sophomoric, unpublishable. He had enjoyed public speaking and television appearances. Now he slurred his words. He was left, he said often, with nothing that he enjoyed in life except smoking — the very cigarettes that probably led to the stroke in the first place. Death had always been his nemesis, but when it finally came, four years after his stroke, I believe he welcomed it.

Stroke is the second-biggest killer worldwide, and the biggest disabler of American adults. It costs the American economy an estimated $74 billion each year. Among its surviving victims, 70% cannot work as they did before, and about one-third need help with basic self-care. Having seen its damage first-hand, I find myself always watching for word of progress on stroke as I scan the research news, and usually struck by how little there seems to be.

Why is there so very little good news, so few breakthroughs? What is so hard about stroke?

In answer, Dr. Randie M. Black-Schaffer, medical director of the stroke program at Spaulding Rehabilitation Hospital, offered this vivid analogy:

Say it’s wartime, and a bomb is dropped in a field. It’s relatively easy to fix, you just regrade the dirt and sprinkle some grass seed. That’s what happens when you get a skin wound. It’s not hard to get the cut to heal up almost as good as new.

World War Two bombing near Paris

Now say the bomb is dropped not on a field but on a town. A great many things have to happen for that town to start functioning again as a town. You start by clearing out the debris — which is like the inflammatory processes in the brain that clear out the cells killed by the stroke. Then you rebuild the buildings, but buildings alone do not make a town. You have to bring the people back, which is like bringing back the blood cells and the neurons. And then the town has to be connected to other towns, by road and by phone lines. And even then, the pattern of movements of goods and services to and from the town may never quite be the same.

In short, Dr. Black-Schaffer said, “It’s just so complex when you have damage in the brain. There are so many different components and systems involved in each functional area of the brain. They all have to be working right in order for the patient to be able to carry on the function.”

Given that image of a bombed town, it is amazing that researchers have made any progress at all. But they have. Lately there have been a couple of exciting findings, and they come against a longer-term background of growing, hard-won understanding of stroke’s effects in the brain. All in all, enough progress for a round-up of promising steps forward.

Herewith, ten relatively bright spots:

1. Overview: Treatment of stroke has advanced — though not as dramatically as hoped — and lab research has come a long way in recent years. Continue reading

Was CBS Reporter’s Grammy Garble A Sign Of Stroke? Possibly.

http://www.youtube.com/watch?v=D9oVf1arcyE

It’s easy to understand why this video of CBS reporter Serene Branson speaking gibberish during a live Grammys report has gone viral on the Web. It’s the quintessential nightmare. You’re speaking on live TV and suddenly your tongue — or your brain — is unable to produce a coherent sentence. I feel a cold sweat coming on just thinking about it.

But the video may also offer a good “teachable moment” about the warning signs of stroke, the brain clots or bleeds that kill more Americans every year than anything except cancer and heart disease. The American Stroke Association’s warning signs are here, and they are:

I asked Dr. Randie M. Black-Schaffer, medical director of the stroke program at Spaulding Rehabilitation Hospital, whether the video looked like a stroke in the making.

“Yes,” she replied, “she is exhibiting a fluent aphasia, suggesting dysfunction in the posterior left side of her brain. This can be due to various problems, including but not limited to stroke or TIA.” (TIA, or a Transient Ischemic Attack, is also known as a “mini-stroke” or “warning stroke,” and can signal danger of a real stroke.)

“Seeking medical evaluation is definitely in order,” Dr. Black-Schaffer said.

Dr. Lee Schwamm of Massachusetts General Hospital agreed: “This is a great teachable moment, and anyone no matter what their age who starts speaking like that is potentially having a stroke. 911 should have been called immediately, and i assume it was, and she should have been transported to the nearest stroke center in the area.”

I’ve just posted a special report on stroke here. Here’s its bottom line: Stroke treatment has advanced in recent years, but not as much as hoped, and the greatest advances by far are for stroke patients who seek treatment fast. If I had Serene Branson’s symptom, I’d be calling 911 before the cameras stopped rolling.

By the way the Los Angeles Times reports here:

Medical experts appearing on TV news shows pointed to her slurred speech as evidence that she might indeed have suffered a mild brain attack. The CBS Los Angeles station for which Branson works, however, said that she now feels fine and has had a follow-up visit with her doctor for tests. It also has removed the video from its website.

Rev. Peter Gomes: May Stroke Not Silence This Ringing Harvard Voice


If you’re religious, now is a good time to pray that stroke will not silence one of the best-known orators of our time: Harvard’s Rev. Peter J. Gomes.

According to the Harvard Crimson, a colleague says that Rev. Gomes, 68, has been able to communicate with visitors since his stroke on Friday but “will not be preaching in the near future.”
And The Boston Globe says here that “’There are signs of improvement, both in his ability to speak and in his physical response,’’’ said Wendel Meyer, a longtime friend and an administrator and preacher at the church.”

Rev. Gomes, a Baptist minister, is considered one of the country’s most prominent preachers, and has written several popular books. He’s long been a central figure in religion at Harvard; and though he’d been planning to retire in 2012, that date may have to be moved up, colleagues say.

I’ve asked Spaulding Rehabilitation Hospital for a specialist to speak broadly about speech recovery from stroke, and am hoping for inspiring examples from history of orators who returned to the podium. But for now, I’d like to share a flashback of Rev. Gomes’s mellifluous powers. This is from a story I wrote for The New York Times way back in 1998, about a special sermon he delivered to graduating seniors:

‘You are going to be sent out of here for good, and most of you aren’t ready to go,” Mr. Gomes, gowned in cherry red, told more than 1,000 seniors in genteelly ringing tones that called to mind a cross between a Shakespearean actor and the sitcom character Frasier.

”The president is about to bid you into the fellowship of educated men and women, and you know,” he paused and slowed, ”just — how — dumb — you — really — are.”

He paused again for the cheers of agreement.

”And worse than that, the world — and your parents in particular — are going to expect that you will now be among the brightest and best,” Mr. Gomes continued. ”But you know that you can no longer fool all the people even some of the time. By noontime today, you will be out of here. By tomorrow, you will be history. By Saturday, you will be toast. That’s a fact — no exceptions, no extensions.”

Having stated the problem, the minister moved quickly to alleviate it, promising students that their best years were yet to come, and that God would be with them.

”The future is God’s gift to you,” Mr. Gomes said. ”God will not let you stumble or fall. God has not brought you this far to this place to abandon you or leave you here alone and afraid. The God of Israel never stumbles, never sleeps, never goes on sabbatical.”

He added, ”Thus, my beloved and bewildered young friends, do not be afraid.”

Mr. Gomes concluded with a benediction: ”God grant you life until your work is done, and work until your life is over.”