ACUTE CORONARY SYNDROME- DO YOU KNOW THE SYMPTOMS?

The acute coronary syndrome (ACS) describes patients who are experiencing symptoms of inadequate blood flow to the heart (myocardial ischemia), or who are experiencing an actual heart attack (myocardial infarction).  Patients who are experiencing ACS should see a qualified emergency room or cardiology physician immediately, as there is abundant research evidence showing that the early diagnosis and treatment of ACS leads to improved survival, and improved heart function in survivors.

Most of us know the classic g and symptoms of ACS, including the acute onset of crushing chest pain, which sometimes radiates to the left arm or the left jaw.  However, for many patients with heart disease, ACS can present without these classic “textbook” symptoms.  These atypical ACS symptoms can include any of the following: isolated pain (i.e., without chest pain) in the right or left arm, upper back, neck, jaw or upper abdomen (the latter is often perceived as “indigestion”); shortness of breath; the new onset of weakness or extreme fatigue; fainting or the feeling that one is about to faint; nausea or vomiting; and palpitations or other abnormal heart rhythms (patients with diabetes and elderly patients are more likely to experience these atypical signs and symptoms, rather than the classic signs and symptoms associated with ACS).

Certainly, it is understandable that many lay people who have no personal history of coronary artery disease might not be aware of the atypical signs and symptoms of ACS, but one would think that patients with a known history of myocardial ischemia or prior myocardial infarction would have a pretty fair idea regarding both the typical and atypical signs and symptoms of ACS.  However, a clinical study, just published in the journal Archives of Internal Medicine, suggests that almost half of patients with a history of ischemic heart disease were ill-informed about the signs and symptoms of ACS.

This multi-institutional study was conducted by researchers at the University of California (the San Francisco and Los Angeles campuses), the University of Pennsylvania, the University of Washington, the University of Kentucky, the University of Nevada (Reno), and other institutions in the United States and Australia.  In this clinical study, 3,522 patients with a history of either heart attack or a prior medical intervention for coronary artery disease participated in a survey designed to assess their knowledge about the symptoms of ACS, as well as the appropriate steps that should be taken by patients experiencing the symptoms of ACS.  The average age of these patients was 67, and 68% of these study volunteers were men.

The researchers defined a score of less than 70% on the survey as being representative of a low level of knowledge.  The average score among all of these adults with a history of significant coronary artery disease was only 71%.  Moreover, the scores of 46% of the participating patients, or nearly half of the patients, fell within the “low knowledge” range!  When the researchers analyzed factors that were associated with higher knowledge scores on the survey, they found that the following factors were statistically significant predictors of adequate or excellent knowledge about the symptoms of ACS:  female gender, younger age, higher levels of education, previous participation in a cardiac rehabilitation program, and receiving care by a cardiologist rather than an internist or general practitioner.  A prior history of heart attack or coronary artery bypass surgery (ABG) was not associated with a higher level of knowledge as tested by the survey, however. 

The results of this clinical study are rather provocative, and suggest that more needs to be done to educate patients at high risk of experiencing ACS, including those who have already experienced episodes of ACS in the past.  When ACS occurs, delays in diagnosis and treatment can truly become a matter of life-and-death.  If you believe that you are experiencing the symptoms of ACS, then please do not ignore them.  Instead, you should seek appropriate medical assistance, and without delay!

 

GREEN TEA & LUNG CANCER

Lung cancer remains the most common cause of cancer-associated death in the United States more than 40 years after the link between smoking and lung cancer was first publicly disclosed by the US Surgeon General.  In 2008, the American Cancer Society estimates that approximately 215,000 new cases of lung cancer will be diagnosed (almost evenly split between men and women), and about 166,000 Americans will die of this highly lethal cancer.  The greatest tragedy surrounding this greatest of cancer killers is that more than 95% of lung cancer cases could be preventing simply by eliminating smoking.  When I hear people complain that the war on cancer has not delivered dramatic reductions in the incidence of most cancers, I immediately think about lung cancer.  In 2008, and there will be an estimated 566,000 deaths due to cancer in the United States, and more than 166,000 of these deaths, or 29% of all cancer deaths, will be due to a cancer that is almost completely preventable (i.e., simply by leading a reasonably healthy lifestyle)….  For these reasons, and because the available treatments for most cases of lung cancer are rarely successful in eradicating all traces of cancer, I rarely include reviews of lung cancer research clinical studies in this column.  However, an intriguing research paper, just published in the journal Carcinogenesis, looks at the effects of an extract of green tea upon lung cancers induced in laboratory mice.  This study was conducted by researchers from the University of Cincinnati, the University of Minnesota, and Washington University.

In this laboratory study, a decaffeinated extract of green tea leaves was added to the diet of mice after they were injected with a mutagenic chemical known to cause lung cancer in mice. A control group of additional mice received injections of the cancer-causing chemical, but did not receive the green tea extract in their diet.  While green tea extract supplementation did not appear to reduce the overall number of lung cancer tumors that developed in the mice, it did appear to significantly reduce the maximum size of the lung tumors when compared to the tumors that developed in the control group of mice.  Using both MRI scans of the lung tumors and microscopic evaluation of lung tumors after the mice were euthanized, the researchers confirmed that the mice that had received green tea extract supplementation had significantly smaller tumors than the untreated control group mice.

While green tea extract did not appear to prevent the development of lung cancer in mice treated with a chemical (benzo[a]pyrene, which is also present in cigarette smoke) known to induce this type of cancer in laboratory mice, dietary green tea did appear to reduce the progression of the resulting lung tumors.  As with all animal-based research studies, however, extrapolating the effects of various treatments on laboratory animals to humans requires a big leap of faith.  In some cases, humans do respond in similar ways as has been observed in laboratory animals.  In many other cases, what appears to work in mice turns out not to work (at least to any clinically significant degree) in people.  However, this research article joins hundreds of others that suggest a modest-to-moderate anti-tumor effect associated with green tea polyphenols for at least some types of cancer.  Currently, there are 25 registered clinical research trials underway in the United States that are looking at the effects of green tea supplements on the development and progression of various types of cancer, including lung cancer.  Hopefully, at least some of these trials will confirm a beneficial effect of green tea supplementation in humans, as has previously been observed in cell cultures and animal studies.  Meanwhile, please do your part in the war against cancer.  If you don’t currently smoke, then please don’t start.  If you already smoke, then please quit, now.

EPISIOTOMY & SUBSEQUENT DELIVERIES- AN UNKIND CUT

Increasingly, obstetricians, and their patients, are questioning the traditional wisdom about routinely performing episiotomies in the delivery room.  An episiotomy involves making an incision on the edge of the vaginal wall and perineum as the baby’s head descends within the vaginal birth canal.  In theory, the episiotomy is a “controlled” laceration of the highly sensitive perineal tissues between the vagina and rectum, and was originally thought to reduce the incidence of deep tears of these tissues, including the sphincter muscles of the anus and rectum.  (After the baby is born, the episiotomy is then repaired by the obstetrician with sutures.)  However, in recent years, the beneficial effects of episiotomy, if any, have increasingly been called into question.  In fact, recent clinical research studies have confirmed what many new mothers, their husbands, and even many obstetricians, have long suspected, and that is that episiotomies often appear to cause the very same injuries and long-term complications that they are intended to prevent.  These complications can leave women incontinent, and with chronic perineal pain that often interferes with their ability to comfortably have intercourse for months, and sometimes for years.  Ask any new mother (or her husband) who has delivered children both with and without an episiotomy which delivery left her with the greatest amount of perineal pain, and for the longest amount of time…. 

If, as it is becoming apparent, episiotomies do not prevent perineal and anal sphincter complications during most routine deliveries, then what might the effects of episiotomies be during subsequent births?  A new research paper in the journal Obstetrics & Gynecology provides some answers to this question.  The researchers reviewed the medical records of more than 6,000 women who underwent at least two consecutive vaginal deliveries at the University of Pittsburgh.  They found that 48% of these women underwent episiotomy with their first delivery.  The researchers then compared the incidence of complications among these women who had received episiotomies with the remaining 52% of women who did not undergo episiotomy during their first delivery.  The results were both striking and concerning.

Among the women who had previously received an episiotomy, 51% experienced moderately severe perineal lacerations during their subsequent second vaginal delivery, while only 27% of the mothers who had not undergone a previously episiotomy suffered similar perineal lacerations.  Severe lacerations that involved the anal sphincter muscle (and which can lead to painful bowel movements and incontinence) occurred in almost 5% of the women who had previously undergone an episiotomy versus just under 2% of the women who had not received a previous episiotomy. 

In summary, this retrospective clinical study adds to a growing body of research suggesting that episiotomy almost certainly does more harm than good, at least for relatively routine deliveries.  In fact, the very birth-associated complications that episiotomy is supposed to prevent are actually more common in women who have been subjected to this procedure than in those who have not received an episiotomy.  While there may still be an occasional indication for episiotomy if the vaginal canal cannot safely accommodate and deliver a large or malpositioned baby, in the vast majority of cases of otherwise normal and spontaneous vaginal delivery, there appears to be no clinically valid reason, any longer, for episiotomy. 

If you are pregnant, it might be wise to raise this issue with your obstetrician, as many obstetricians who continue to routinely perform episiotomy consider the procedure to be an integral part of their obstetric care, and some obstetric physicians may, therefore, plan to perform this generally unnecessary, and potentially harmful, surgical procedure without first discussing it in detail with their patients. 

Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center:

http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html

Send your feedback to Dr. Wascher at:  rwascher@doctorwascher.net

http://www.doctorwascher.com

Copyright 2008.  Robert A. Wascher, MD, FACS.  

All rights reserved.

Share on digg

 

EARLY CHILDHOOD SCREENING PREDICTS LATER BEHAVIORAL PROBLEMS

Significant emotional or behavioral problems are often not detected until affected children begin school.  Moreover, even in moderately severe cases, children with emotional and behavioral problems may not receive appropriate screening and intervention until they have been in school for several years.  Researchers from the University of Connecticut and the University of Massachusetts have just published the results of an interesting study, in the journal Pediatrics, in which they screened children for behavioral and psychological problems at a very early age, and then followed them as they subsequently entered elementary school.

A total of 1,004 socio-economically and ethnically diverse children were evaluated in this study.  The children’s parents completed a standardized Brief Infant-Toddler Social and Emotional Assessment survey when their children were between 12 and 36 months of age (the average age of the children participating in this research study was 24 months).  These children were again evaluated once they entered elementary school, at an average age of 6 years.  Both parents and the children’s teachers participated in this latter evaluation of social and behavioral problems in this large group of children. 

Among those infants and toddlers with evidence of social, developmental and emotional problems detected upon their initial evaluation, 49% were reported, when these children subsequently began elementary school, to have significant behavioral and social difficulties in class, based upon their teachers’ evaluations.  The initial Brief Infant-Toddler Social and Emotional Assessment and Evaluation survey also predicted which babies and toddlers would later develop significant criteria for psychiatric disorders.  Among those infants and toddlers who had evidence of developmental or behavioral difficulties on their initial survey, more than two-thirds (68%) were found to meet the criteria listed for specific psychiatric disorders after reaching elementary school.

As a disclaimer, I will mention that the disciplines of Psychiatry and Psychology are rather unique among the clinical sciences in that it is very difficult (if not impossible) to obtain completely objective research data in clinical research studies such as this one.  Human behavior is extremely complex, variable, and unpredictable.  Thus, unlike research studies that randomize different groups of patients to receive different medical therapies, or studies that involve laboratory experiments, clinical psychiatric and psychological research studies cannot completely control all of the experimental factors that might skew either the resulting data, or, for that matter, its interpretation.  Therefore, I generally do not include such studies in my column.  In this case, however, I chose to include this particular study, because I believe that it may be helpful for some parents (and teachers) to know about its findings.

While I absolutely do not advocate performing routine psychiatric testing on children who do not have any evidence of significant behavioral or psychiatric problems, the results of this study suggest that it may be possible to pick up evidence of significant behavioral or/and psychological problems in the majority of “at risk” children long before they begin their school years.  While not every child with “abnormal” scores on the Infant-Toddler evaluation survey ultimately experienced psychiatric illnesses by the time they reached elementary school, in this study, more than two-thirds of such children were, in fact, subsequently diagnosed with a psychiatric disorder after starting elementary school. 

Perhaps, if identified during late infancy or while still a toddler, children who are at high risk of developing significant emotional or psychiatric illnesses might be able to undergo more intensive early screening and, if appropriate, begin therapy before they start attending school.  If effective therapy is available prior to beginning elementary school for any significant emotional or psychiatric illnesses that are identified early, then these children might have a much more positive and successful experience at school in their later years.

 

PSYCHIATRIC DISORDERS AMONG PARENTS OF AUTISTIC CHILDREN

The incidence of autism in the United States has been, inexplicably and dramatically, rising in recent years.  According to the Autism Society of America, autism is currently diagnosed in 1 of every 150 children born, and approximately 1.5 million people in the US are thought to have an autistic disorder.  Currently, the care of autistic patients is thought to cost around $90 billion per year, and some experts predict that this cost will rise to $200 billion dollars, or more, within the next 10 years.  There is also evidence, from the London School of Economics, that the early diagnosis and treatment of autism can reduce the lifetime cost of caring for such patients by as much as two-thirds (in most cases, the difficulties in communication and social interactions that are the hallmarks of autism can usually be detected within the first 3 years of life).

There is a great deal of debate about the potential causes of autistic disorders.  Recent studies have shown that at least some cases of autism do appear to be linked to specific gene mutations, suggesting that some cases of autism are very likely a result of inheritance.  There has also been a tremendous controversy regarding autism and its link, if any, with childhood vaccinations (and the mumps, measles and rubella, or MMR, vaccine, in particular).  However, multiple rigorous clinical research studies have, so far, failed to find any link between the development of autism and vaccinations.  In most cases, autism is diagnosed during the same age range as when children are beginning to receive their immunizations, and many public health experts have suggested that this factor is the most likely explanation for the apparent onset of the symptoms of autism following vaccinations. 

A new Swedish study, also just published in the journal Pediatrics, takes a look at the incidence of psychiatric illnesses in the parents of children who have been diagnosed with an autistic disorder.  As is the case in most of Scandinavia, and in much of Europe, essentially the entire population has access to universal healthcare provided by the federal government and its contractors.  It is for this reason that huge numbers of patients can be followed in clinical research studies in such countries, as a wide range of clinical data is routinely entered into central public health databases, even in countries with relatively small populations. 

This particular study was the result of collaboration between researchers from Sweden’s famed Karolinska Institute, the University of North Carolina at Chapel Hill, and the Mount Sinai School of Medicine here in New York.  Using the Swedish Medical Birth Register and the Swedish Multi-Generation Register, and other centralized public health databases, the researchers identified 1,227 children born between 1977 and 2003 who were subsequently treated for an autistic disorder.  For comparison purposes, more than 30,000 other children born during the same interval, but without any history of autism, were also included in this research study.  The researchers were then able to further assess this public health data to determine the incidence of treatment for psychiatric disorders among the parents of both groups of children born between 1977 and 2003 (editorializing for a moment here, and needless to say, conducting a study like this is never likely to be approved here in the United States).

In this study, the incidence of mental health disorders among the parents of autistic children was found to be significantly greater than what was observed among the parents of the much larger “control” group of parents of non-autistic children.  Specifically, schizophrenia was found to be more common in both mothers and fathers of autistic children, while depression and personality disorders were found to be more common among mothers of autistic kids, only.

While the results of this study, as with previous studies, suggests that at least some cases of autism might be inherited (and might be associated with other psychiatric disorders that are also thought to be heritable), one must be very careful in drawing conclusions from this data.  Certainly, caring for a child with autism, or other serious mental or physical illnesses, is a tremendously taxing and stressful undertaking.  I can easily imagine that parents who are faced with, potentially, the lifelong care of a severely disabled child could rather easily succumb to the stresses of such demands by developing emotional or psychiatric illnesses themselves. 

Unfortunately, this study, which was based solely on confidential public health records in Sweden, cannot tell us very much about the details of mental illness among parents of autistic children.  Also, as I have already mentioned, virtually all clinical studies involving psychiatric testing and evaluation are associated with a significant likelihood of subjectivity and bias, due to the inherent complexity of assessing human behavior and personality.  All of these disclaimers aside, this study still suggests that at least some significant percentage of autism cases may be linked to specific genetic factors which, in turn, may also be associated with other psychiatric illnesses within families.  The recent identification of specific gene mutations associated with at least some cases of autism also suggest that many (but not all) cases of autism are likely to be the result, at least in part, of specific and potentially heritable genetic factors.

 

SOCIAL & PSYCHIATRIC PROFILES OF YOUNG ADULTS BORN PREMATURELY

As neonatal intensive care units have become increasingly sophisticated in caring for extremely premature babies, more and more of these tiny infants are surviving into adulthood.  There have been numerous clinical research studies published about this group of patients, with some studies finding a significant increase in the incidence of lifelong physical and mental health difficulties among those who were very premature at birth.  As is often the case with public health research, there have also been quite a few studies published that have suggested that most people who were born prematurely do just fine if they survive into adulthood.

A new Dutch study in the Journal of Pediatrics, which was part of a larger ongoing study of children and adults born prematurely, evaluated 656 healthy adolescents who were born very prematurely, and compared them with their same-age peers with respect to general lifestyle, risk-taking behaviors, the presence of psychiatric disorders, and social interactions. 

Interestingly, both the teenage boys and teenage girls who had been born prematurely were less likely to smoke than their peers who had been born after a full-term pregnancy.  The teenage boys born prematurely were also less likely to drink alcohol than their full-term counterparts, while the adolescent girls who were born prematurely consumed alcohol as often as the girls who were born at full-term.  Lifetime illicit drug use was also significantly less common among the teens (boys and girls) who were born prematurely, when compared to their full-term birth peers.  With the notable exception of using public transportation without paying the fare… the adolescents born prematurely were far less likely to be involved in criminal activity than the kids who born at full-term.  Although the boys born prematurely appeared to experience greater difficulty in establishing relationships than their full-term peers, on the whole, the incidence of psychiatric disorders did not differ significantly between the two groups of adolescent boys and girls.

Healthy adolescents who were born “very pre-term,” or at a “very low birth-weight,” like those who were included in this study, represent a very select subgroup of young adults who have managed to grow and thrive, and to achieve excellent overall health, despite severe prematurity at birth.  In this particular subgroup of young adults born very prematurely, risk-taking behavior appeared to be less common than was observed in the general population.  At the same time, increased difficulties with initiating new relationships appeared to be more common among the teens who were born prematurely, especially among the boys.  While the explanations for these differences in social behavior between the two groups of teens is not unclear, they are nonetheless intriguing and worthy of further study.

 

Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center:

http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html

Send your feedback to Dr. Wascher at:  rwascher@doctorwascher.net

http://www.doctorwascher.com

Copyright 2008.  Robert A. Wascher, MD, FACS.  

All rights reserved.

Share on digg