I was prompted to write about this when, in the last week or so, a couple of patients presented with upper back-pain in between the shoulder-blades and dismissed them off as ‘muscular aches’. In both cases, they turned out to be impending heart attacks. So what kind of symptoms are produced when the heart’s in trouble?
The reality is not all heart attacks happen suddenly and dramatically as in a TV drama where you clutch your chest in pain and fall to the ground. In many instances, the warning symptoms appear but are ignored because they appear in unusual parts of the body and may fade off after a while, only to reappear again especially when the heart is stressed.
The classical symptom is that of central chest-pain or pressure, not unlike someone standing on your chest. But sometimes, the pain can be in unusual locations include jaw or teeth pain, leading to a visit (wrongfully) to the dentist. An alert dental surgeon can recognise the differentiating features and refer the patient on to the cardiologist for urgent attention.
Another location for heart-attack pain can be the so-called interscapular area (the part between the shoulder-blades), even without chest-pain. Often, the pain can be excruciating with possible pain-free intervals, leading one to a false sense of security with disastrous consequences; because time is crucial in such circumstances : the well-known ‘golden hour‘, named because early treatment during an evolving heart attack can mean the difference between life and death.
Pain need not always be present as a heart attack develops. Especially in diabetics, breathlessness can be the only symptom. Of particular note is progressive deterioration of stamina, such as walking up a staircase.
Getting treatment within an hour of a heart attack cuts your risk of dying from it in half, so it is important to get to the nearest Emergency Department of a large hospital in double-quick time. Sometimes it may be better to rely on one’s own transport than to wait for an ambulance if that’s going to save time.
Are there any useful measures to do while waiting to receive medical attention? Anecdotally, several maneuvers have been promoted on the Internet, many without a proven basis. There’s certainly no place for home remedies! Sitting up and facilitating breathing (loosening tight clothing) and at the same time calming the patient does help as it is well-known that anxiety aggravates the heart. If aspirin is available (even the ones for headaches), putting a tablet under the tongue will help to thin out blood and prevent clots from developing.
Personally, I have encountered several instances where people hesitate to go to the hospital for fear of embarrassment in case it turns out to be a false alarm. Others deliberately neglect to call help, fearing the worst, but hoping their inner fears may be wrong. In any case, an important rule of thumb is that it is better to be proven wrong at the hospital than to miss a heart attack. No medical staff is going to chastise you, for sure, if you’re wrong.
- 20 Classic Heart Attack Signs Never To Ignore (positivelygood.net)
On his deathbed, it was purported that Alexander the Great summoned his generals and told them of his three last wishes:
1. The best doctors should carry his coffin;
2. The wealth he has accumulated (money, gold, precious stones) should be scattered along the procession to the cemetery, and
3. His hands should be let loose, hanging outside the coffin for all to see.
Surprised by these unusual requests, the generals asked him to explain and this was his reply:
1. I want the best doctors to carry my coffin to demonstrate that, in the face of death, even the best doctors in the world have no power to heal.
2. I want the road to be covered with my treasure so that everybody sees that material wealth acquired on earth, stays on earth.
3. I want my hands to swing in the wind, so that people understand that we come to this world empty handed and we leave this world empty handed after the most precious treasure of all is exhausted, and that is TIME. TIME is our most precious treasure because it is LIMITED. We can produce more wealth, but we cannot produce more time.
True or not, these quotes do carry significant lessons in life.
As a doctor, I am particularly attracted to the first point. Sometimes, we do face situations where relatives do expect us to prevent or postpone the inevitable; not only is this impossible but it results in humbly putting doctors and care-givers in their place..that the Almighty proposes and man disposes. Yes, and one’s time is finite.
Doctors are not God and many doctors, including myself, live by this credo:
“To cure sometimes, to relieve often, to comfort always”
-ascribed to Hippocrates (Greek physician, 460-370 BC)
People who count housework as exercise could be fooling themselves, research has suggested. Until now, studies have suggested housework counts towards a weekly round-up of moderate exercise activity.Such housework activities included gardening, DIY, vacuuming or cleaning.
In a study published in the journal BMC Public Health, experts found that those who counted housework as exercise were actually heavier than people choosing other forms of exercise. The study, published in more detail here went on to say that such activity may not be sufficient to provide all of the benefits normally associated with meeting the physical activity guidelines. In other words, the energy expended during housework was insufficient to burn off enough calories to make one maintain or lose their weight.
Personally, I’ve maintained for a long time that when it comes to exercise, in particular heart (cardiovascular) fitness, the intensity and duration should be any form of continuous strenuous physical activity which should be at least 25 minutes duration three times a week. Even the so-called weekend ‘jogging’ does not meet this criteria if there is no midweek activity put in place.
- Housework ‘not strenuous enough’ (bbc.co.uk)
I wasn’t too surprised reading the other day that health-related matters take up 2% of all queries on internet search engines. In fact, I thought the figure would be higher, judging from day-to-day conversations with patients.
The big question of course is: how reliable are the facts dished out on the Internet? Obviously, its important that these websites are reliable and churn out accurate information. Even so, healthcare information is complicated by a few other factors not related to the reliability of these websites, as explained later.
How do you identify reliable websites? First of all, as a yardstick, websites sponsored by the governments, not-for-profit health or medical organizations, and university medical centers are the most reliable resources on the Internet. Sites supported by for-profit drug companies, for instance, who may be trying to sell you their products, are usually not your best option. Also note that medical info changes rapidly with time and a look at the dateline of the article is important. Here are a few such sites:
Medlineplus.gov - sponsored by the National Institutes of Health and managed by the U.S. National Library of Medicine, MedlinePlus provides information on more than 900 diseases and conditions in their “Health Topics” section, and links to other trusted resources.
WebMD provides a wealth of health information and tools for managing your health from an award-winning website, which is continuously reviewed for accuracy and timeliness.
MayoClinic.com – owned by the Mayo Foundation for Medical Education and Research, this site is produced by more than 3,300 physicians, scientists and researchers from Mayo Clinic, and provides in-depth, easy-to-understand information on hundreds of diseases and conditions, drugs and supplements, tests and procedures.
Sometimes,even with reliable trustworthy information, its rather difficult for the untrained public to give due weightage to the complex info that is being bombarded onto them. For instance, when reading the side-effects of a particular medication, it is difficult to appreciate that not all the listed side-effects will invariably occur when one consumes the drug.
This is why its better to consult a doctor to obtain clarification. It takes years of medical training to adequately decipher fully what’s found on web health-sites and to fully appreciate its implications.
In fact, the over-reliance of info on the internet has given rise to a new condition called cyberchondria (aka internet self-diagnosis) – this refers to the practice of leaping to dire conclusions while researching health matters online. If that severe headache haunting you in the morning led you to the Web search-engine and a search on ‘headaches’ led to ‘brain tumours’ or ‘meningitis’, people tend to look at the first few results in the search-engine which forms the basis for them to probe further till they are convinced that they have a brain tumour. The likely diagnosis is probably cyberchondria than anything else! The phenomenon has become so pervasive that Microsoft did its own study on the causes of cyberchondria way back in 2008.
Last month, it was reported that an American, Michael Boatwright was discovered unconscious in a Motel 6 room in California , but when he awoke could not remember anything about himself, recognize even his own reflection, nor how to speak English.
Even though his driver’s license says he was born in Florida and served in the U.S. Navy from 1971 to 1973, Boatwright has no memory of his life to date and now answers only to Johan and converses in Swedish to doctors with the help of an interpreter.
This brings to mind several similar cases in the past where apparently normal strangers have been seen to be aimlessly walking around in total amnesia, with no recollection at all on their name or background.
As in this case, the cause has been attributable to a medical condition called transient global amnesia - a sudden, temporary episode of short-term memory loss that cannot be attributed to conditions like epilepsy or stroke (which are known causes of temporary amnesia).
What causes this condition? Basically, any sudden stress to the brain, whether in the form of sudden immersion in cold water, physical strain, mental stress, head injury or even sexual intercourse. They tend to occur in those over 50 and who suffer from migraine. It is thought that in all of the above conditions, there is a temporary constriction of the blood vessels going to the brain, causing temporary brain malfunction.
The good news is that the condition is temporary and usually resolves within 24 hours. No treatment is required and the condition seldom recurs.
Back to Michael Boatwright. It turns out that the American had lived in Sweden in the 1980s where he learnt to speak good Swedish and was known as Johan Ek. He was identified by members of the Swedish branch of the Society for Creative Anachronism, where he was a keen participant of the group’s jousting team. So, mystery solved..
Its all very well for big pharmaceutical companies (pharmas) to release a new medication with a big bang , what with the enormous money invested in its research, development and production . However, not often enough, such new launches become unstuck when unexpected side-effects appear after a few months on the market, despite the most strenuous prelaunch testing and extensive marketing as a blockbuster-to-be.
Unexpected side-effects aside, what’s potentially more serious is when clinical trials (designed to prove a drug’s efficacy before its official launch) are falsified, thereby giving end-users erroneous data proclaiming (falsely) the drug’s efficacy. Such appears to be the case with regards to the Kyoto Heart Study.
What was the significance of this study? This study by Japanese scientists was greeted with great fanfare in 2009 and centres around the ability of a medication ,already extensively used for the treatment of high blood pressure, to reduce the possibility of getting stroke by 50% when used in high-risk patients. This was a milestone in drug treatment for hypertension and enabled the maker, Novartis , to make it one of the best-selling drugs in the world.
The drug itself, valsartan, which is marketed as Diovan has been on the market since around 2001 for the treatment of hypertension and belongs to the new group of ARBs (angiotensin-receptor blockers). In fact, its patent expired in 2012, thereby enabling any pharma to produce its own version, so-called generic drug.
And now the bombshell: Last Friday, Japan’s minister of health, Norihisa Tamura, as well as university officials at Kyoto Prefectural University announced that the Kyoto Heart Study data were “very likely” fabricated, Apparently, incomplete data was used and some of the scientific investigators were in fact employees of Novartis.
The reaction to this has been deafening. the respected European Heart Journal retracted the study from its 2009 issue. There has been widespread condemnation among medical circles, resulting in the resignation of the principal Japanese investigator from the Kyoto University, Dr Matsubara.
This episode puts into perspective the over-reliance of the efficacy of new medications on so-called landmark scientific studies, whose integrity may be subject to the temptations of big bucks and commercialism. Often, the losers are the consumers themselves.
Lots of hospitals claim to have world-class facilities and boast of being the region’s best, but what really does it take to be one? The mere presence of a five-star hotel lobby with expensive chandeliers and smiling receptionists definitely is not one criteria. Lest we forget, people come to a hospital with a problem they want fixed; the rest are just superfluous and complementary.
The best medical centers for the most difficult patients - that’s how the US News & World Report decides which are the best hospitals in the US, for example. They have been publishing annual rankings of the best hospitals in the US since 1991. The latest list was released last week:
US News & World Report Top Hospitals Honor Roll 2013
1. Johns Hopkins Hospital, Baltimore, Maryland
2. Massachusetts General Hospital, Boston
3. Mayo Clinic, Rochester, Minnesota
4. Cleveland Clinic, Ohio
5. Ronald Reagan University of California–Los Angeles Medical Center
6. Northwestern Memorial Hospital, Chicago, Illinois
7. New York–Presbyterian University Hospital of Columbia and Cornell, New York City
8. University of California–San Francisco Medical Center
9. Brigham and Women’s Hospital, Boston
10. UMPC-University of Pittsburgh Medical Center, Pennsylvania
Its interesting to note from the above list that Johns Hopkins was displaced from its top spot only once – last year in 2012 – when it went to the current runner-up. All the top five have consistently retained their top five status.
The magazine awards points to hospitals based on the individual specialty rankings. In 12 of the 16 specialties, measurable performance in terms of quality of care, safety, and mortality accounts for two thirds of a hospital’s score. The institution’s reputation among specialists, ascertained by a survey, accounts for the remaining one third.
You can read more, including the best hospitals for each specialty here.
So what does it take to be a world-class hospital? Apart from good outcomes, the following are also important:
1. Innovation - A desire to practice in an environment that embraces evidence attracts nurses and other staff to these hospitals.
2. ‘Patient-first’ philosophy – a no-brainer really, but quite easily forgotten by hospitals who pay too much attention to the financial bottom-line. They often forget that its the patients (read ‘customers’) who are paying their salaries!
3. Collaboration – Teamwork creates better outcomes, and many of these hospitals have embraced fostering greater collaboration between disciplines. Every discipline brings a special domain of practice, knowledge and skill to create a village of information.
4. Quality Improvement- Structured processes for clinical services allow staff to define and sustain clinical practice standards and incorporate new findings into practice. Care processes and measures for success can be defined and measured via a balanced scorecard.
5. Quality Nursing Care – Patients come to the hospital expecting the best doctor and often, they will get one for their medical condition to be treated appropriately. What can make the difference is the nursing. When nurses add on compasssion on top of the usual nursing skills, they give that extra edge to that hospital’s reputation.
6. Positive Work Environment – Nurses form a key component in any hospital, and to retain and attract them, the hospital management has to create an environment where people will want to work in. In my experience, a good pay is important but this is not the be all and end all. Other factors come into play like professional satisfaction and empowerment.
7. Continuing Education – one of the factors enhancing point 6. We are looking not at just professional education, but also at social skills like complaints management.
8. Staff Engagement – When you engage people closest to the work , you respect them.They want to know where the organization is going and what the driving value is, and you can demonstrate how their work contributes to that. That includes letting the staff know as and when new staff are brought in as part of succession planning.
In my years as a hospital manager, the above values keep on recurring time after time and quite often, many hospitals do not make it to the top quite simply because the above lessons are not assimilated. Let me reiterate, good clinical outcomes are a must.
Face-masks come in many shapes and sizes. One normally associates them with surgical masks, which is meant to prevent germs from the wearer contaminating the environment. However, the haze which is affecting Southeast Asia is another story..
The Southeast Asian haze event is caused by continued uncontrolled burning from “slash and burn” cultivation in Indonesia, and affects several countries in the Southeast Asian region because the prevailing southwesterly winds carry the pollutants across the water – see below.
What are haze particles composed of? Haze particles are predominantly made up of fine particles that are 2.5 micrometers or smaller. This means using an ordinary facemask, whether single-ply, 2 ply or 3 ply, hardly protects the wearer effectively from the haze particles Its designed to keep the germs in and should be worn by those having viral illnesses like flu. Nevertheless, ordinary surgical masks will reduce the inhalation of haze particles but NOT eliminate them completely.
To eliminate haze particles completely, one needs to wear a N95 mask (so-called because these masks eliminate 95% of particles as small as 0.1 micrometers (or microns). It must be tight-fitting and is rather uncomfortable to wear over long periods as extra effort is sometimes needed to inhale.
For this reason, the N95 mask is a must for those with lung problems, those with reduced immunity and those who have to be in the open for prolonged periods (like traffic cops).
For those who are otherwise healthy and stay indoors most of the time, ordinary surgical masks may be adequate. In all cases, adequate hydration is important mainly to facilitate the removal of the haze particles which have lodged in the lungs.
- Singapore’s Great Haze exposes limits of e-commerce (sgentrepreneurs.com)
Some patients asked recently whether coffee was good for one’s health. They had apparently noticed that there has been the shift in marketing strategy by coffee-makers in promoting it as a rich source of anti-oxidants, and therefore beneficial to health.
YES, coffee is a rich source of anti-oxidants, like chlorogenic acid and melanoidins, the latter being the most important component of roasted coffee. Some of the other beneficial effect of drinking coffee include:
- Reducing the incidence of Parkinson’s Disease and Alzheimer’s. Read “A Cup of Coffee a Day will Keep Alzheimer’s Away”.
- Protecting against diabetes. Moderate consumption may lower the risk of type 2 diabetes in younger and middle aged women.
- Preventing liver disease and the formation of liver and kidney stones.
- The beneficial effects of caffeine in coffee on alertness, attentiveness, and wakefulness.
NO, among other things:
- Unfiltered coffee (as in Turkish coffee and kahawa) raises blood cholesterol. Filtered coffee, as in instant coffee, does not do so as diterpenes, responsible for raising cholesterol, are removed by filtration.
- Coffee consumption is also associated with an increase of plasma homocysteine, a risk factor for coronary heart disease.
- Caffeine in coffee can increase the risk of elevated blood pressure and hardening of the arteries, as well as palpitations.
- 4 cups or more will hasten osteoporosis, especially in those with low calcium intake in the diet.
- Coffee increases heartburn, aka gastro-eosophageal reflux disease (GERD).
What about heart disease? The verdict’s not in just yet..on one hand, diterpenes cause a rise in cholesterol and homocysteine but this seems balanced by the beneficial anti-oxidant properties. As of now, there is no convincing evidence that coffee leads to heart disease, period.
I ought to clarify here that we are talking about coffee, just plain coffee. The pendulum swings the other way when we consume coffee with additives, like milk and sugar. The latte at the local Starbucks will add on quite a substantial amount of fats, sugars and calories (260 to be precise, see here). Compare that to the ZERO calories of plain black coffee!
The effects of the current outbreak of the H7N9 avian influenza in China has been as varied as causing the sales of KFC to drop and causing the stock-prices of rubber-glove manufacturers to be on the uptrend..but there’s no mistaking the fact that to date, there has been 9 deaths and 28 confirmed cases (see here).
But a mystery is brewing..the first known human case was in eastern China on Feb. 19, but this was not announced to the public until March 31, some 6 weeks later. This delay in announcement is even being questioned by the heavily censored news media, such as the Communist Youth Daily, the official newspaper of the Communist Youth League.
Was there deliberate concealment by the health authorities? The answer may not be that straightforward. Possible reasons for the delay may include that the new virus strain shows unusual properties and that Chinese laboratories might have been doing tests to detect the previous H5N1 strain instead. To recap, the H5N1 outbreak struck in 2003 where a total of 247 people died. Measures instituted at that time included the controversial administration of several million vaccines to the chicken population at a significant economic cost. This could also be a reason why the news has been suppressed.
Avian influenza (also called avian flu, bird flu) is a flu virus that infects poultry but can be transmitted to man by direct or indirect exposure to infected live or dead poultry or contaminated environments. It is generally classified of low virulence (it does not spread to man easily). There is no evidence that the disease can be spread to people through properly cooked food. You can get more info from the WHO Fact Sheet here.