Dabigatran

The first new drug is dabigatran, brand name Pradaxa. It’s an oral anticoagulant, a blood thinner that can be taken by mouth. It treats atrial fibrillation, a common heart rhythm abnormality that predisposes patients to strokes. Most atrial fibrillation patients take warfarin (brand name Coumadin) for this purpose.

Dabigatran prevents strokes as well as, or better than, warfarin, with about the same risk of unwanted bleeding. And it doesn’t require blood test monitoring. Warfarin patients must have blood drawn at least every month and more often when starting the medicine, changing the dose, sick, changing other medicines, etc. So dabigatran can be a boon for people who have trouble maintaining correct warfarin levels or trouble complying with the recommended testing.

Alas, dabigatran is no panacea. It must be taken every 12 hours rather than once daily for warfarin. It’s expensive, costing twice as much as warfarin even factoring in the required blood tests. Warfarin can be reversed with the injection of vitamin K, but there is no antidote if a patient develops excessive bleeding on dabigatran. Patients with serious bleeding on dabigatran need transfusion of fresh frozen plasma. Also, dabigatran is sensitive to moisture and must be used within 30 days of when the bottle is opened.

Denosumab

Another new drug approved in the past year is denosumab (brand name Prolia), an injection for the treatment of osteoporosis in postmenopausal women. It’s a monoclonal antibody: an actual specific human antibody produced in the laboratory. It’s given as an injection every six months delivered in the doctor’s office.

Our bones are always remodeling: old bone is reabsorbed and new bone formed. After menopause, bone breakdown often exceeds new bone production, leading to the bone thinning and structural changes of osteoporosis. Denusomab binds to a chemical called RANK ligand, a substance involved in bone breakdown. Denusomab slows both bone breakdown and overall bone remodeling.

In the three-year study leading to the drug’s approval, women taking denusomab had fewer fractures and higher bone density than controls. The medication is approved in special situations, such as women who have failed other osteoporosis treatments, or who have been unable to tolerate other medications.

Because the drug is new, the incidence of serious side effects remains unknown. Scientists don’t yet know whether denusomab will cause the same serious problems over time that were discovered in other osteoporosis drugs. These problems include osteonecrosis of the jaw, atypical thighbone fractures, or delayed healing of fractures. Known side effects include back, muscle, and bone pain, elevated cholesterol, and bladder infections. Because denusomab’s target, the RANK ligand, is also involved in the immune process, women taking Prolia have an increased risk of infection.

Propoxyphene

Propoxyphene (brand names Darvon, Darvocet) has been discontinued. It’s a weak pain reliever, no more effective than acetaminophen. It can cause abnormal heart rhythms, even in patients without known heart disease. Regular users of propoxyphene should taper off the drug to avoid withdrawal, rather than stopping cold turkey.

Meridia

Abbott laboratories withdrew its popular weight loss drug Meridia from the market several months ago. The FDA recommended discontinuing Meridia because its modest effects for weight loss were not worth its increased risk of heart disease.

Super Glue, Ear Wax

The website that I used to research the above turned out to have a section that I hadn’t noticed before, called “Truth vs. Rumor.”  It looks at the evidence supporting various medical rumors. I thought I’d share some knowledge gained from browsing that information.

Can superglue be used to repair skin wounds? I learned that the cyanoacrylate chemical used in household super glue is similar to, chemically different from the chemicals used in medical tissue glue. It’s probably safe to use household superglue for tiny wounds like cracked fingertips or paper cuts. Don’t use super glue on chronic wounds or larger wounds that require closure. Medical adhesives degrade more slowly than household superglue, lasting longer and causing less toxicity.

Can sodium docussate, an over-the-counter stool softener, help soften earwax? There aren’t any studies that show superiority of any one of various substances that have been tried to soften ear wax: commercial wax softeners, hydrogen peroxide, sodium bicarbonate, olive oil, or sodium docussate. But it’s safe and painless, so go ahead and try if desired.

Skin ulcers of the lower legs become more common with age for a variety of reasons. The most common ulcers develop when the veins that return blood from the legs deteriorate.

Because blood in the leg veins must run uphill to return to the heart, leg veins come equipped with valves to keep blood from being pulled back down by gravity.

Some people inherit fewer valves or valves that give out early. Valves can be damaged by injury, blood clots (venous thrombosis) or vein inflammation (phlebitis.)

Calf muscles also aid return of blood from the legs. Their contraction squeezes the veins. Injury, immobility or just plain inactivity can impair the leg vein function.

When blood pools in the veins, it backs up blood in the capillaries, the smallest blood vessels that ultimately feed into the veins. Stretching the capillaries damages their walls, releasing substances that cause inflammation.

This damages the skin of the lower legs.

The most common location is near the ankle, especially just above the medial malleolus (the inner ankle bone). At first, the ankles swell. The swelling generally decreases overnight when the patient lies flat, only to progressively worsen over the course of the day. The skin stretches, and develops a rash similar to eczema with redness, dryness, and scaling. The legs often ache. Over time, pigments leaking from the pooled blood discolor and darken the skin. Eventually the skin breaks down to form an irregular shallow ulcer.

Once an ulcer appears, treatment involves compression, leg elevation, dressings, medication, and sometimes surgery. Compression reduces pain and swelling, enhances return of blood from the veins, and hastens ulcer healing. Compression may be elastic, inelastic or mechanical.

Elastic compression conforms to leg size and therefore is effective during both rest and activity. Either stretchable bandages (ace wraps) or compression stockings can be used. Compression stockings are superior because they are capable of applying higher pressure and can be graded to apply the highest pressure near the ankle with decreasing pressure toward the knee and thigh.

Inelastic compression consists of bandages, like an Unna boot, that don’t stretch. While not as effective as elastic compression, there are times when, as a doctor, I find it helpful. The Unna boot is one brand of inelastic compression dressing made of moist gauze impregnated with zinc oxide. The doctor applies it, and it hardens (not as much as a cast) and stays in place until removed several days later.

For the patient who can’t — or won’t — apply compression stockings, it jumpstarts the healing process and ensures that the patient is actually complying with the doctor’s recommendation. But they’re messy, and if the ulcer is draining a lot, they can smell.

Mechanical pressure devices encircle the legs. A pump inflates and deflates them to provide a pumping action. They are expensive and cumbersome and so are used for bedridden patients who can’t tolerate other compression methods.

Leg elevation means getting the legs above the level of the heart. Ideally this happens three to four times daily for 30 minutes at a stretch. That’s not always possible especially for working people. Even lesser degrees of leg elevation speed ulcer healing, and reduce swelling.

There are dozens — if not hundreds — of types of dressings to choose from: hydrocolloids , hydrogels, foams, pastes, and more. But so far studies have not proven any one dressing superior to others. So the best choice is something that isn’t too expensive, is easy to use, and preferred by the patient or doctor.

Infected venous ulcers require antibiotics by mouth. For ulcers without infection, oral antibiotics don’t hasten healing. There is limited evidence for the usefulness of topical antibiotics. In any case, leg elevation, appropriate dressings, and leg compression are the first line treatments.

Large or stubborn venous stasis ulcers sometimes require skin grafting. Fortunately this is rarely needed. There is a role of surgery to treat venous insufficiency to reduce the risk of recurrent venous stasis ulcers.

The financial cost of venous stasis ulcers is huge because nearly 1 percent of the population is affected. The estimated price tag is $2 billion per year in he United States.

If you have leg concerns that may be related to poor vein function, ask your doctor whether you might benefit from compression stockings, vein surgery, or other preventive measures.

And if you do develop an ulcer, get treatment right away. Small problems are easier to fix than big ones.

She definitely needs the medicine because she had her thyroid gland removed years ago to treat a cancerous tumor. And her doctor has closely monitored her thyroid level for years.

I asked her how she can be sure that this medicine, which she has taken for over 30 years without problems, caused her arm to hurt?

She replied that she stopped the medicine for five days and now her arm feels better, so the medicine must have caused the pain. Right?

That’s what scientists call anecdotal evidence. It’s one story, or anecdote. But it’s not really proof that stopping the thyroid medicine made her arm stop hurting.

A lot of things can make arm pain disappear; perhaps the most likely explanation is that a minor sprain or strain went away with the passage of time.
To really determine whether a treatment works—whether it’s adding a medicine, stopping a medicine, performing an operation or something else—it’s necessary to study the treatment scientifically. One highly effective method is called a randomized controlled trial (RCT).

In that type of experiment, patients are randomly assigned to the treatments that are being compared. For example, one third of the patients might receive a low dose of a study medicine. Another third would take a higher dose of the study medication. And the last third might take a placebo, or might take a known effective treatment for comparison.

Whenever possible the study is “blinded.” In a double blind RCT, neither the treating doctor nor the patient knows what treatment the patient is receiving. In a single blind RCT, the doctor knows what treatment the patient is receiving, but the patient does not.

The blinding reduces bias.

For example, patients who know that they are receiving active medication might expect to feel better and report more improvement than the patients who know they are receiving placebo. Or the active medicine group may expect, and therefore report, more side effects.

But anecdotes are very appealing, and are often very persuasive, especially for people who haven’t been trained to think via the scientific method.
Anecdotes are stories, and the human brain evolved to learn from stories. We didn’t evolve to learn things by performing statistical analysis; it’s a learned art.

One reason anecdotes are so appealing is that we often identify with the person reporting the story. If your best friend swears that a particular cream prevented a cut from scarring, it’s hard not to believe it. You like your friend. You trust your friend. She wouldn’t lie to you. If you don’t believe her, the emotional part of your brain feels bad, as if you are accusing your friend of lying.

Even when the logical part of your brain tells you that your friend really can’t know whether her success was due to (1) the expected disease course (the initial cut and the patient’s skin type would have healed without scarring regardless of treatment) or (2) the placebo effect (your friend expected the cream to work and so overlooked minor scarring.)

Human beings are designed to be emotional creatures, and anecdotes, often in the form of testimonials, are often effective marketing ploys precisely because they appeal to our emotions.

There’s curiosity: what happened and how did it work? There’s vanity: it worked for me, and it might work for you, too, because you are special. There’s hope: the doctors say nothing can be done but someone tells the tale of something that worked for them. And fear: if I don’t try this, will I miss the one thing that might have worked?

Anecdotes are not bad. The problem arises when people fail to recognize that they aren’t sufficient proof of what works or doesn’t work. Anecdotes can be a valuable starting point for scientific inquiry. If 100 people all claim that a particular treatment successfully cured a medical problem, then maybe it’s worth scientific investigation.

Back to my relative with the arm pain. If she really wants to know whether the thyroid medicine made her arm hurt, she could restart it. If the pain comes back, she could stop the medicine and see if it goes away. And repeat this several times to see if it is a reproducible effect. But I wouldn’t recommend it in this case. Thyroid hormone is required for normal metabolic function, and a person with no thyroid simply cannot get it from taking vitamins or changing her diet. And there’s no plausible reason to expect thyroid hormone to start causing arm pain after 30 years.

Scientific studies aren’t perfect. That’s why new treatments seldom become the accepted standard after one study shows a favorable outcome. Most doctors and scientists prefer to wait until several different groups investigate new treatments and replicate favorable findings.

Can you imagine doing the same thing over and over again, 100,000 times each day for decades? And getting it right almost every time? That’s what the human heart does. Your heart beats regularly several billion times over a normal lifespan in order to pump and circulate 2,000 gallons of blood every day.

Amazingly, your heart does this without fancy electronic or mechanical controls. The signal to contract arises at regular intervals from a small cluster of cells called the sino-atrial (SA) node. The SA node is located in the upper chambers (atria) of the heart. The electrical impulse causes the atria to contract, pumping blood to the lower heart chambers (ventricles). The electrical signal travels in special conducting fibers to the atrioventricular (AV) node. The AV node is another cluster of specialized cells that delays the signal a bit so that it will reach the ventricles after the atria have contracted and filled them with blood. After the passing through the AV node, the electrical signal continues to the ventricles. The ventricles then contract, so that the left ventricle can send blood to the body and the right ventricle can pump blood to the lungs.

The description above is how things are supposed to work, and most of the time that’s the way things happen. But sometimes the system runs awry, and the heart rhythm is disrupted. That’s called an arrhythmia.

Types of Arrhythmias

• Premature beats — The heart may throw in an early beat, before the next regular beat is due. This premature beat may arise from either the atria or the ventricles. Premature beats are the most common type of arrhythmia. The vast majority of the time they are not dangerous, and often go unnoticed. Stress and caffeine both increase the occurrence of premature beats.

• Atrial fibrillation — This abnormal rhythm affects 3-5 percent of all Americans. It’s the most common type of medically dangerous arrhythmia. In atrial fibrillation, the atria cease beating regularly and instead quiver ineffectively. Blood may pool in the atria, leading to blood clots. These blood clots can break loose, potentially traveling to the arteries in the brain. Blockage of brain arteries can cause a stroke. The quivering atria don’t fill the ventricles properly, potentially causing insufficient blood to be pumped to the body and lungs. And the lack of an effective pacemaking impulse from the SA node causes the ventricles to contract irregularly, often too fast, too slow, or alternating between too fast and too slow.

• Bradycardia — Bradycardia means that the heart beats too slowly. It may be normal and cause no symptoms in a well-conditioned athlete. Or it can cause problems due to lack of sufficient blood circulation. Certain types of medicines can cause bradycardia.

• Tachycardia — Tachycardia means that the heart beats too quickly. It some cases it is a physiological response to fever, blood loss or dehydration. It can arise from an overactive thyroid. Or it can be due to a diseased cardiac electrical system.

• Ventricular arrhythmias — Normally the ventricles don’t contract until they receive a signal conducted from the upper portion of the heart. But sometimes the ventricles begin beating on their own. This may be ventricular tachycardia, a very fast rhythm that is seldom stable for long. Or there may be ventricular fibrillation, a potentially lethal arrhythmia where the ventricles quiver ineffectively and don’t circulate the blood at all. If prompt CPR and electrical defibrillation do not restore circulation, irreversible brain damage begins in 3-5 minutes.

Symptoms—Arrhythmias may cause palpitations — the sensation of the heart beating too quickly or irregularly. If an arrhythmia compromises blood circulation, a patient can feel short of breath, weak, lighted headed, or dizzy. There may be chest pain. Serious arrhythmias can cause loss of consciousness ranging from a brief faint to cardiac arrest.

If you experience an occasional brief palpitation with no associated symptoms, see your doctor soon to be checked. But for anything more serious, call 9-1-1 and head to the emergency room by ambulance. Don’t drive yourself or have friends and family drive you when you are experiencing the symptoms of potentially serious heart disease!

Diagnosis—An exam and EKG identify many heart rhythm disturbances. But many arrhythmias come and go, and may disappear before you see a physician. In that case you may need a Holter monitor, which observes the heart rhythm for 24 (or more) hours. For infrequent problems, you may need an event monitor, a device that the patient wears for days and activates when the symptoms occur. Certain arrhythmias are evaluated by an electrophysiological (EPS) study, where a cardiologist inserts electrodes into the heart to observe the electrical activity.

Treatment—The treatment of cardiac arrhythmias has involved tremendously since 1950, due to improved medications, new electrical devices, and invasive procedures.

Frequently used medicines include:
• Warfarin: a blood thinner that decreases the risk of blood clots in atrial fibrillation
• Antiarrhythmics: help maintain the heart’s normal rhythm. Examples are amiodorone and sotolol.
• Beta-blockers: slow the heart rate by limiting the effect of adrenaline on the heart.
• Calcium channel blockers: slow the heart rate and suppress tachycardia.

Devices that help treat arrhythmias include pacemakers and implantable cardiverter/defibrillator (ICD). An ICD detects life-threatening arrhythmias and delivers a shock to terminate the rhythm before the rhythm terminates the patient.

An example of an invasive procedure is cardiac ablation. Catheters are inserted into the heart to map the source and electrical route of the abnormal rhythm. If the abnormality is identified, radiofrequency energy can be delivered through the catheter to target a select group of hear muscle cells. A scar forms, blocking the abnormal electrical pathway.

Here’s a final tidbit. It turns out that Monday is the most common day for arrhythmias to occur. Scientists think this is because of stress. Interestingly enough, the Monday association occurs even in retired people!

Eva Briggs, a board-certified physician, works on the staff at Cayuga Medical Center in Ithaca, in its two urgent care centers: one in Ithaca, and the other in Cortland.

The older you get, the greater your chance of being treated for a cardiovascular condition, such as high blood pressure, heart attack, heart failure and heart rhythm abnormalities.

Fortunately there are many medications available to treat these conditions. But many patients—and their doctors—aren’t aware that many of these medicines interact with over-the-counter herbal supplements. And some of those interactions are deadly.

What is an herbal supplement, anyway? Simply defined, it’s any part of a plant or a plant product. They are not subject to the same regulations as drugs. The only requirement is that the manufacturer sends a copy of the label to the U.S. Food and Drug Administration (FDA). The ingredients are not tested for safety or efficacy. The ingredients can be new and experimental. A lack of quality control means that labeling can be inconsistent and the actual amount of ingredients can vary widely from lot to lot. Repeated studies have shown that contamination with heavy metals, adulteration with pharmaceuticals and prohibited ingredients are often found.

Even though herbal products are touted as “natural,” they may still cause adverse reactions in some patients. The true incidence of such reactions is underreported for several reasons. First, patients who assume that herbal supplements are always safe often don’t recognize that a problem that they experience may be due to a supplement. So the patient doesn’t report the event to the FDA, the manufacturer or the doctor. Patients often don’t think to report supplement use to their health care providers, and providers often fail to specifically ask about supplement use.

Two common medications in particular that are susceptible to interactions with herbals are the blood thinner warfarin (Coumadin) and digoxin used to treat failing heart muscle and certain abnormal heart rhythms. If an herbal medicine increases the metabolism of warfarin, the drug will be less effective, and the patient may experience the unwanted blood clotting that warfarin is supposed to protect against. This can cause stroke, as well as blood clots in the legs, lungs or arteries of the heart. Conversely, some herbals slow the metabolism of warfarin, which permits higher levels to accumulate, leading to increased risk of bleeding. This can cause strokes due to bleeding within the brain, gastrointestinal bleeding and other unwanted bleeding.

Herbals that alter the metabolism of digoxin can cause heart rhythm abnormalities and other heart problems. If an herbal raises the digoxin level, a patient can develop the signs of digitoxicity: confusion, nausea and vomiting, palpitations and serious abnormal heart rhythms, and vision changes.

Herbal products can affect other drugs used to treat cardiovascular conditions. This includes, but isn’t limited to, beta-blockers, antiarrhythmics, and cholesterol lowering drugs.

Be sure to tell your doctor if you are taking any herbal supplements!

One common herbal preparation is St. John’s wort, purported to treat depression, insomnia, anxiety and other conditions.

This medicine affects an enzyme called CYP3A4, which metabolizes approximately 50 percent of all prescription medications. St. John’s wort increases this enzyme, hastening the elimination of drugs metabolized by CYP3A4, and reducing their effectiveness. St. John’s wort markedly decreases the level of the anti-rejection drug cyclosporine, used after organ transplant, and has caused organ rejection.

Another popular supplement is ginkgo. It’s claimed to alleviate the symptoms of Alzheimer’s disease, but there is no convincing evidence yet that it is effective for this disorder. But when taken along with many medicines used to decrease the risk of blood clots, it can increase the risk of unwanted bleeding. Bleeding has been reported in the brain, in the eye and the abdomen.

Echinacea is popular because it is alleged to stimulate the immune system and prevent infections. Evidence so far shows no benefit in treating or preventing infection with rhinovirus, the virus that causes the common cold. But if used for long periods, it can increase the risk of liver damage due to certain medications, especially those used to lower cholesterol.

While herbal medicines are growing in popularity, remember that their purity, effectiveness, and safety are often unknown. Until these products are better studied and regulated, wise consumers should be aware that they are using them at their own risk. If you take any prescription medications, be sure to let inform your prescriber about use of herbals. It could save you from a dangerous drug interaction, or even save your life.

Eva Briggs, a board-certified physician, works on the staff at Cayuga Medical Center in Ithaca, in its two urgent care centers: one in Ithaca, and the other in Cortland.

“Knowledge is power,” stated Francis Bacon, a philosopher who established and popularized an inductive methodology for scientific inquiry five centuries ago. With a new year and a new decade, it’s time for you to seize hold of your own personal medical knowledge. Following is a summary of things you should know about your own medical history.

• Your current medical history. Learn the correct names and details of any medical conditions that you have. It’s not enough to be aware that you have “heart disease.” That broad term covers a wide range of possibilities. Is your heart disease coronary artery disease, in which the arteries to the heart muscle are diseased? Is it congestive heart failure, a disorder in which the heart muscle is weak? Or is it atrial fibrillation, an abnormal heart rhythm? If you don’t know your diagnoses, make it a point to ask your doctor. Problems that are controlled by medication or lifestyle still count as part of your medical history. If you have high blood pressure or diabetes that is under control, it’s still important.

• Your past medical history. Learn the names of medical problems that you’ve had in the past. If you were admitted to a hospital, why were you in the hospital? What kind of surgery have you had?

• Your current medications. It’s not enough to tell your health care providers that you take a little white pill for your blood pressure. There are many little white pills out there. Instead, learn the following information about your medicines: the names of your medicine, the strength, and how often you take the medicine (one pill three times a day? Three pills once a day?). Also learn why you take each medication.

• Your allergies. Learn the names of medications to which you’ve had a reaction, and learn what kind of reaction you experienced.

• What is the name of your pharmacy? Whenever possible, you should get all your prescriptions filled at the same pharmacy. When a person receives medications from several different doctors, it’s possible for one doctor to prescribe a medication that could interact with another pill ordered by a different prescriber. If you fill all your prescriptions at the same pharmacy, the pharmacist can identify potential harmful drug interactions.

• What are the names of your doctor(s)? Even though you’d think this would be obvious, the number of people who can’t remember the name of their regular physician amazes me. “You know,” patients often tell me in the urgent care, “the guy over in the medical office building that’s near one of the hospitals—I can’t remember which one—he’s a nice guy, short hair, somewhere between 35 and 55 years old…..” That describes a lot of doctors! Learn the names of any specialists that you see, as well as the name of your primary care provider.

• Your personal health statistics. Learn items that are relevant to you. For example, if you are being treated for high blood pressure, what is your usual blood pressure? If you have diabetes, what is your usual blood sugar?

Once you have gathered the above information, write it down. Put it in your wallet or purse and carry it with you. Keep it up to date. If you type it up on your computer, you can edit it and print a new copy when something changes. If you keep a handwritten copy, then re-write it if there are so many corrections that it is no longer legible. Keep a copy at home where your family can locate it in case of an emergency.

As a last piece of organization for the new decade, clean out your medicine cabinet and dispose of medicines that are no longer needed or are outdated. That will prevent you from accidentally taking the wrong medicine and reduce the chance that someone in the household will inappropriately self-treat an  undiagnosed medical problem.

When my mother suffered a serious disabling stroke 15 years ago, a stroke that ultimately killed her, there wasn’t much that medicine could offer. The stroke happened while she was eating dinner with my brother and his fiancé, who prompty called an ambulance. But even immediate treatment at a medical center made little difference for her.

Stroke remains the third leading cause of death in the U.S., and the No. 1 cause of disability. But new developments in stroke treatment are beginning to make the outlook for stroke victims less bleak.

Stroke occurs when something runs amok with the vessels that supply blood to the brain. The brain requires a steady supply of oxygen and fuel (glucose) to operate, and begins to malfunction and die as soon as its supply is disrupted. Blood vessels are like pipes, and as with your plumbing, there are two basic ways that they can go wrong. First, they can leak and burst. Second, they can become clogged and blocked.

A common source of bleeding is a berry aneurysm. Think of this as a weakened area of a blood vessel that balloons out over time. The defective area where the aneurysm fails is probably congenital, something the patient is born with. Risk factors include a family history, certain genetic diseases that affect connective tissue, head trauma, high blood pressure, infection, tumor, atherosclerosis and cigarette smoking.

Most berry aneurysms don’t cause any symptoms until they rupture and hemorrhage. At that point symptoms can include headache, weakness, trouble speaking and confusion. A few patients’ aneurysms leak slowly first and produce a warning “sentinel” headache. Occasionally a berry aneurysm is discovered incidentally when a patient undergoes testing to evaluate an unrelated condition.

One treatment is brain surgery. The surgeon carefully removes a segment of the skull, then opens the covering of the brain, and finally attempts to carefully locate the aneurysm. Once located, the aneurysm is clipped: a special metal device seals off the aneurysm where it bulges from the blood vessel.

Of course, brain surgery is invasive. So an exciting new technique is beginning to be used more often. Called endovascular embolization, it begins with the surgeon threading a flexible hollow plastic catheter into the groin. The catheter is carefully threaded through the vascular system until it reaches the berry aneurysm. Next a guide wire is threaded through the catheter and used to position tiny coils of platinum wire inside the aneurysm. Eventually the aneurysm is filled with more coils, which cause the blood inside to clot and destroys the aneurysm. The whole setup is tiny, with a catheter smaller than the tube inside a Bic pen and the wire scarcely bigger than a human hair!

The second way that a stroke can occur is when the pipes become clogged. One way this can happen is when a blood clot breaks loose from somewhere upstream, perhaps from a blood clot within the heart. It’s similar to what happens when your kid drops a toy into the toilet and it becomes stuck when it can’t negotiate the curve in the drainpipe. Or the build- up of plaque can gradually narrow an artery to the point where a blood clot forms in the narrowed segment or the plaque itself ruptures and blocks the artery. Strokes caused by any form of blocked blood flow are called ischemic strokes, and are the most common type of stroke.

One treatment for this type of stroke is to use a drug that can dissolve blood clots. It’s like pouring in drain cleaner. But this type of treatment can be problematic: there is an increased risk of bleeding elsewhere in the body, and there are lots of situations where these drugs aren’t safe, such as after recent surgery or in a patient with ulcers.

Now, in selected cases, surgeons can actually thread a catheter to the blocked area, and then use tiny wires to snare the clot, pull it back (like reeling in a fish) and then suck it out with a tiny suction catheter.

Thanks to these new techniques, modern medicine is beginning to succeed in treating a condition that only a few years ago carried a uniformly grim prognosis. Stroke is still a serious dangerous disease. The ultimate goal would be to prevent stroke from happening in the first place. We’re not there yet, but stopping smoking and controlling high blood pressure, high cholesterol, and diabetes definitely helps.

Even the most exciting new technologies can help only if started as soon after the onset of a stroke as possible. Think of it as a brain attack. Like a heart attack, stroke is an emergency. If you believe your family member, friend or coworker is having a stroke, call 911. Don’t waste time by waiting, or by driving to a doctor’s office.

Signs of a stroke, according to the American Stroke Association, are:

• Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body.
• Sudden confusion, trouble speaking or understanding.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance or coordination.
• Sudden severe headache with no known cause.

This issue I’m writing a little about the 10 top selling nutrition and health supplements. It’s a big industry in the U.S., grossing $23 billion dollars a year.

Remember that items marketed as supplements are regulated differently than medicines. While some supplements are assembled in laboratories, others are not much more than bagged up lawn clippings packaged in someone’s garage and labeled with misleading claims. Look at least for supplements that are labeled USP grade, which means that the U.S. Pharmacopoeia randomly tests some batches. Or look for the GMP—good manufacturing practice—label. Supplements made in Europe are generally subjected to higher quality controls, while those imported from Asia are notorious for the possibility of contamination and mislabeling.

1 – Multivitamins—These are the good old workhorses of the vitamin world, and they are not unreasonable for most people. In the ideal world, of course, we’d all eat a variety of healthy foods and get all the vitamins and minerals that we need from our diets. While most Americans get plenty of calories, we’re not so good at getting a healthy variety of nutrient- rich foods.

2 – Meal Replacements—These are items designed to replace home- prepared meals and include souped-up granola bars such as Zone bars, breakfast drinks, and more elaborate plans like Nutrisystems. They shouldn’t completely replace a regular diet, but they do have a place. For people who have been over-eating for years, they serve as a reminder of what healthy portion sizes should look like, and can jump-start efforts at weight loss. They can provide a healthy alternative to fast food when you’re in a hurry and don’t have time to cook a meal. But many are high in sodium so check the label. And they won’t replace the rich variety of nutrients you’ll get from a diet including a variety of fruits, vegetables, and whole grains.

3 – Sports Nutrition—This covers a gamut, from electrolyte replacement solutions to assorted supplements claiming to increase muscle mass. For most people, replacing fluid is the key requirement when exercising. And that can be done with plain old bargain priced tap water. The extra sodium and potassium found in electrolyte replacements probably isn’t needed unless you are in an endurance sport or exercising in the extreme heat. And energy drinks? Read the label; that’s usually a code word meaning caffeine, which is best avoided when you exercise.

As for supplements designed to increase muscles or boost your performance? There’s no evidence they work, so save your money to use on healthy foods or to join a gym.

4 – Calcium—This is a nutrient that is hard to consume in sufficient amounts in the diet. Dietary sources include dairy products, green leafy vegetables, and whole grains. But spinach and wheat bran contain substances that prevent the absorption of calcium, and cottage cheese’s high salt content also makes that a poor source for calcium. If you’re over 50, you need 1,200 mg. of calcium per day. The National Institute of Health (www.niams.nih.gov/Health_Info/Bone/Bone_Health/Nutrition/calcium_intake.asp) has information online to help determine your calcium requirements and to calculate your dietary intake.

5 – B Vitamins—These include B12, folate, and B6, and they are included in most multivitamins. In order to absorb B12 you need to have acid in your stomach. So people taking medicines for GERD (gastroesophageal reflux disease) may need extra B12, to make up for decreased absorption. The good news is that most people don’t need injections, because large oral doses of B12 overcome the decreased absorption. B12 shots are useful short- term to quickly boost levels in patients who have severe deficiencies.

6 – Glucosamine/chondroitin—The jury is still out on whether glucosamine with chondroitin is effective in osteoarthritis, because study results have been conflicting. You can read more from the National Institute of Health—nccam.nih.gov/research/results/gait/qa.htm. But it seems safe, so it’s reasonable to try. Remember that if it does help, it may take weeks to months before you see a reduction in osteoarthritis pain.

7 – Vitamin C—If you have a cold, gobbling down big doses of Vitamin C won’t help. This is one vitamin where megadoses can harm you. Your body excretes excess vitamin C in the urine, where large quantities can from crystals that damage the kidneys.

8 – Homeopathy—Many people mistakenly believe that homeopathy is another word for natural. It’s not; instead it refers to a specific belief system whose practitioners believe that tiny doses of various substances can produce powerful cures. But homeopathic remedies are so diluted that they are nothing more than expensive water containing few if any molecules of the supposedly therapeutic molecules. Don’t waste your money.

9 – Vitamin D—It’s tough to get sufficient Vitamin D from diet and sunlight alone in this climate. And the RDA (recommended daily allowance) found in multivitamins is probably too low. The RDA of 200 IU (international units) will prevent the bone disease rickets, but it’s not enough to prevent osteoporosis and to optimize cardiovascular health. Aim for at least 1,000 IU per day.

10 – Fish Oil—These provide healthy omega-3 fatty acids that benefit the cardiovascular system. But be careful with high doses over 2 grams per day, which can increase the risk of bleeding, especially if you are taking a blood thinner such as warfarin (Coumadin). Quality can vary widely, even within different lots of the same brand, because it easily becomes rancid. You can test your bottle of fish oil by taking out a capsule, poking it with a pin, and squeezing a drop onto a tissue. Smell it. If it smells OK, then taste a drop. And if that doesn’t taste bad, your fish oil is not spoiled.