Tuesday, October 14, 2014

Takotsubo Cardiomyopathy. How Do You Mend a Broken Heart?

Nicknamed "broken heart syndrome", Takotsubo Cardiomyopathy (TCM) is a temporary condition associated with sudden, severe weakness of the heart muscle. "Cardio" refers to the heart and "myopathy" means muscle disease. Another name for this condition is "stress-induced cardiomyopathy", since it is triggered by emotional or physical stress. The disease was first described in 1990 in Japan, but has not been recognized by American doctors until fairly recently.

Who is Takotsubo?
This is actually a Japanese word that translates into "octopus pot" and does not refer to an individual. A takotsubo is a round-bottomed, narrow-necked vessel used by Japanese fishermen to trap octopuses. When imaging studies of the heart were performed in people with this condition, it was noted that one of the chambers of the heart (left ventricle) assumed the shape of an octopus pot when the heart muscle contracted.
Who gets TCM?
Over 90% of reported cases are in post-menopausal women ages 58 to 75. Emotional stress, such as the unexpected death of a loved one, is a common trigger. Cases have also been triggered by learning bad financial news, domestic violence, legal problems, experiencing natural disasters and being diagnosed with a serious medical problem. Physical triggers include the exacerbation of a chronic medical illness, a car accident, an asthma attack, and a seizure.
What are its symptoms?
At its onset, TCM mimics a heart attack with chest pain, trouble breathing, dizziness and weakness. An important difference, however, between TCM and heart attack is the underlying cause. A heart attack occurs after the arteries that supply blood to the heart become blocked, resulting in damage or death of portions of the heart muscle. In TCM, the heart muscle becomes overwhelmed by an outpouring of stress hormones, such as adrenaline, after experiencing emotional or physical trauma.
How is TCM managed?
Since TCM shares many of the features of a heart attack, including changes on electrocardiogram and elevation of heart muscle enzymes, it is managed in the same way as a heart attack initially. This could include admission to a coronary care unit and imaging studies (dye test) of the heart. In fact, the diagnosis of TCM is usually confirmed during the dye test because an important feature of TCM (along with the takotsubo-shaped ventricle) is that the coronary arteries are found to be normal. This is in direct contrast to the narrowed or blocked coronaries in someone with coronary heart disease. Once it is known that the heart is merely "stunned" rather than damaged, treatment becomes supportive until the heart muscle regains its strength. Medications may be required to improve blood pressure, lower the heart's workload or prevent blood clots.

Friday, October 3, 2014

Sobering findings from a study of alcohol-related deaths

Many times, we tend to think of long-standing conditions, such as chronic liver disease, as being responsible for causing deaths due to excessive alcohol consumption.  A recent study from the Centers for Disease Control (CDC), however, has shed new light on the actual causes of alcohol-attributable deaths. The main goal of this study was to update a previous analysis of alcohol-attributable deaths (AAD) and years of potential life lost (YPLL) in the United States that was performed in 2001.  The study looked specifically at the rates of AAD and YPLL in each state and estimated the number of deaths and YPLL that specifically involved those younger than 21 years. Here are a few of the findings (in bold type) from that study:

  • During the study period of 2006 through 2010, an average of 87,798 deaths occurred each year that were attributed to excessive drinking.  Among working-age adults (ages 20-64), this amounted to approximately one in every ten deaths.  Excessive drinking plays a role in causing a number of conditions including liver failure, acute pancreatitis, psychosis, esophageal cancer, breast cancer, oral cancer, falling injuries, suicide and drowning.
  • It was estimated that excessive drinking was responsible for the loss of approximately two and a half million potential years of life lost each year.  In other words, excessive alcohol consumption shortened the lives of those who died by about 30 years.   
  • Binge drinking, defined as four or more drinks in a sitting for women or five for men, was found to be responsible for 51 percent of all deaths due to excessive drinking.   Binge drinking is the most common pattern of excessive alcohol use in the United States, and most people who binge drink are not alcohol dependent. Binge drinking is linked to an increased incidence of injuries (motor vehicle crashes, falls, drowning, etc.), violent acts (homicide, suicide, intimate partner violence, etc.), acute alcohol poisoning, and miscarriage.  In the United States, a standard drink is considered to be 12-ounces of beer (5% alcohol), 5-ounces of wine (12% alcohol) or 1 ½ ounces of distilled spirits (40% alcohol). 
  • The majority of alcohol-attributable deaths (71%) and YPLL (72%) involved males. One factor that could have contributed to this statistic is that binge drinking has been found to be twice as common among men as compared to women. Among drivers in fatal motor-vehicle traffic crashes, men are almost twice as likely as women to have been intoxicated.
  • The most common cause of chronic AAD was alcoholic liver disease, while the most common cause of acute AAD was motor-vehicle traffic crashes.  In 2011, the number of alcoholic liver disease deaths was found to be 16,749.  Alcohol-impaired driving crashes caused 10,228 deaths in 2010.
  • The highest rate of annual alcohol-related deaths occurred in New Mexico (51 deaths annually per 100,000 people), while the lowest was reported in New Jersey (19 per 100,000).  The study’s authors offered several possible explanations for this difference including state policies on selling alcohol, differences in drinking patterns, and differences in access to health care, including emergency departments.
  • During the years 2006-2010, an average of 4,358 AAD and 249,727 YPLL involved individuals under the age of 21.  Approximately three fourths of these were males. The three leading causes of death in this age group were acute, rather than chronic conditions.  These were--- motor-vehicle accidents, homicide, and suicide. Of these, traffic crashes alone accounted for 36% of the total.
Because of the way that data was gathered, the authors of this study felt that they most likely underestimated, rather than overestimated, the toll on life and life expectancy related to excessive alcohol intake. Of particular concern from this study is the finding that binge drinking is as great a concern as is chronic alcoholism.  The Dietary Guidelines for Americans defines moderate drinking as no more than 1 drink per day for women and no more than 2 drinks per day for men.  The CDC, however, points out that there are some persons who should not drink alcohol at all, including those who are:
  • Pregnant or trying to become pregnant.
  • Taking prescription or over-the-counter medications that may cause harmful reactions when mixed with alcohol.
  • Younger than age 21.
  • Recovering from alcoholism or are unable to control the amount they drink.
  • Suffering from a medical condition that may be worsened by alcohol.
  • Driving, planning to drive, or participating in other activities requiring skill, coordination, and alertness.

Friday, September 26, 2014

Rabies Post Exposure-What should I do if bitten by an animal suspected of being rabid?

Rabies is a potentially fatal viral disease most often transmitted through the bite of a rabid animal. Over 90% of rabies infections in the U.S. occur in wild animals such as raccoons, skunks, coyotes, bats, and foxes.  Transmission to humans can occur when virus-containing saliva of a rabid animal enters its victim from a bite.  Once the virus enters its victim, it travels through nerves to the brain and spinal cord.  On reaching the brain, the virus multiplies rapidly, causing inflammation (encephalitis) along with the initial symptoms of malaise, fever, and headache.  As the disease progresses, other symptoms including excessive salivation, difficulty swallowing, aversion to water, confusion, and abnormal behaviors develop.  At this point, the disease is typically fatal within a few days since there is currently no rabies-specific anti-viral treatment available.  By taking certain measures following exposure to the rabies virus, however, the risk of developing the disease can be significantly reduced.
General measures:  As with most skin wounds, immediate cleansing is an important first step in reducing the likelihood of developing an infection.  Bite wounds should be washed with soap and water and then a topical antibiotic and clean bandage applied. Studies performed on animal models have shown that thorough wound cleaning will markedly reduce the likelihood of developing rabies.  Tetanus immunization, if not received within the previous 10 years, should be given.  Bites are much more likely to transmit bacterial infections, such as those caused by Staph or Strep, than rabies. For this reason, doctors may prescribe antibiotics following a bite injury or with the development of signs of infection (redness, swelling, oozing, etc.).

Post-exposure vaccination:  When exposure to rabies is believed to have occurred, rabies post-exposure vaccination (prophylaxis) should be started promptly.  This consists of both a vaccine that stimulates antibody formation in the body as well as the administration of antibodies to the rabies virus in the form of human immune globulin.  One dose of the human rabies immune globulin and four doses of rabies vaccine given over 14 days is the standard treatment.  The vaccine is usually given in the upper arm muscle and is similar to receiving a flu shot.

Treatment Guidelines:   The specific management of animal bites hinges on a number of factors including the type of animal, the geographic area in which the exposure occurred, the type of exposure, and the health status of the animal involved. Due to the severity of the disease, medical attention should be sought in any instance in which rabies exposure was possible. The following are general guidelines for managing animal bites when rabies is a consideration: 
  1. Bites from healthy domestic animals, such as dogs, cats and ferrets, are at low risk of causing rabies.  In these cases, the animal should be confined by its owner and observed for 10 days.  Assuming the animal remains healthy during this period of time, rabies can be excluded. In these cases, no rabies prophylaxis is necessary.
  2. If the domestic animal appeared ill at the time of the bite or becomes ill during quarantine it should undergo evaluation by a veterinarian.  If rabies is suspected, the victim should begin receiving rabies prophylaxis.  The Centers for Disease Control (CDC) advises that animals suspected of being rabid should be euthanized and examined for evidence of the rabies virus by a qualified laboratory (often the State Health Department).
  3. Raccoons, skunks, foxes, coyotes or bats that bite humans should be considered to be rabid unless proven otherwise by examination of brain tissue.  Post-exposure vaccination should be started promptly.
  4. If the animal responsible for the bite cannot be recovered, it may be safest to assume that it was rabid. Discussing the situation with a doctor and representatives from the State Health Department will help in determining if post-exposure prophylaxis is necessary.  In the case of a stray or unwanted dog and an unprovoked attack, euthanasia and examination of the brain for evidence of the rabies virus may be the best option.
  5. In animals, rabies is diagnosed using the direct fluorescent antibody (DFA) test.  This looks for the presence of rabies virus in brain tissue.  Use of this test, however, assumes that the animal can be captured without causing more injury.  A negative DFA test implies that saliva from the bite did not contain rabies virus and post-exposure prophylaxis is unnecessary or can be discontinued.
Largely as a result of widespread vaccination of domestic animals against rabies, the number of potential exposures to the infection has decreased dramatically in the U.S. Deaths from rabies have dropped from  around 100  in the early 1900’s to 1 or 2 per year currently.   Contributing significantly to this reduction in rabies mortality is post-exposure prophylaxis which, if begun soon after exposure, is almost 100% effective.