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TECHNOLOGY AND SURGERY TO STOP A STROKE
For stroke victims, diagnosis must be quick and accurate. Within 6 hours, it should be medically determined whether the stroke was due to a hemorrhage (bleeding or burst brain artery) or a clot (blocked brain artery). New imaging methods, including CAT and MRI scans, hasten this discovery, which is crucial to proper treatment. If caused by a brain hemorrhage, surgery usually is considered. For a clot, treatment with an antiplatelet medication, such as aspirin, is considered. In some cases, surgery may be needed.
Felix Ticineto, 79, a self-employed accountant from Flushing, New York, suffered a stroke. “I came home, ate, and started bumping around,” he recounts. “I couldn’t walk. I had no balance. I went to sleep without telling my wife and woke up with the problem.”
Dr. Barbut of New York Hospital used an ultrasound transcranial Doppler to help diagnose Mr. Ticineto. This machine sends out sound waves that bounce off internal organs and produce a colored picture showing the patient’s blood flow to the brain. Dr. Barbut says that, with the Doppler, “you can see the clots waft past and even hear them.”
Finding that arteries feeding Mr. Ticineto’s brain were blocked by plaque, she had them scoured in a surgical procedure called an endarterectomy. “I feel great now,” says Mr. Ticineto. “My right hand and arm are a little weakened, but I was very lucky. I work every day.”
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STROKE: RECOGNIZING THE SYMPTOMS
People seem to recognize the symptoms of a heart attack and react readily to aid the person having one. But a stroke often is mistaken for something else, including drunkenness (there may be slurred speech, clumsy motions), and a physician’s care is not sought.
Dr. Stanley Tuhrim, who heads the stroke program at Mount Sinai Medical Center in New York City, says, “We must educate the public and physicians to recognize stroke symptoms and get help. [See the list later for symptoms of stroke.] Heart attack victims get chest pains and call 911. That reaction is needed for stroke.”
“We now think that there’s a lot we can do in the first few hours after a stroke,” adds Dr. Elliot Roth of the Rehabilitation Institute of Chicago, “and that a lot more can be expected and achieved.”
Get medical help within an hour if you experience any of these symptoms:
? Weakness or numbness of the face, arm, or leg
? Dimness or loss of vision, particularly in one eye
? Difficulty in speaking or understanding speech
? Severe headache with no known cause
? Unsteadiness, unexplained dizziness, or sudden falls, especially with any of the other signs
You can also take some preventive measures to help avoid such symptoms. See your doctor and get tested for high blood pressure. If you have it, get treatment. If you smoke, stop.
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NEW ADVANCES CAN STOP A STROKE: PHYSIOLOGICAL RESEARCH
New technology improves diagnosis. Today, doctors sometimes can detect high-risk patients before stroke symptoms even arise.
An important result of all this is a change in attitudes. Physicians once shrugged in defeat at strokes. Now they know that many stroke patients can be rescued, and doctors treat strokes with the same urgency as heart attacks.
The death rate from strokes in the United States has plunged 40 percent in the last 20 years. New treatments cut the risk of stroke by 60 percent in some patients. Many have been helped by the treatment of high blood pressure – a major factor in stroke – through diet or drugs.
“Stroke is one of the most rapidly expanding areas in the brain sciences,” says Dr. Michael Walker, who directs the Division of Stroke and Trauma for the National Institute of Neurological Disorders and Stroke (NINDS) in Bethesda, Maryland.
Physiological Research
It once was accepted that damage from stroke was permanent, because the brain does not replace dead brain cells. But new findings in physical therapy show that, with persistent guidance, the brain can find new pathways, allowing undamaged nerve cells to take over and perform the functions of the dead ones.
Dr. Mark Hallett, a clinical director for NINDS, studies adult stroke survivors who have regained function of a limb after losing partial or total control. Dr. Hallett says he has found that “if you use a body part repetitively, more groups of nerve cells become devoted to it, and this may upgrade its use.
“This suggests,” he adds, “that the brain can be trained to use different nerve pathways to control a once-paralyzed hand, for example. We believe that the brain’s capacity to reorganize itself will help rehabilitation profoundly.”
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SKIN DURING PREGNANCY: ACNE
One of the most common myths is that acne will disappear during pregnancy. Although this does occur in some women, others notice that their acne gets worse or appears for the first time due to sudden hormonal changes.
Unfortunately, treatment options are very limited because many drugs used for acne are not safe during pregnancy. Simple measures are therefore very important. Moisturizers and moisturizing sunscreens should be avoided, and oil free makeup should be used.
Topical antibiotics, such as clindamycin lotion, are safe during pregnancy, as are benzoyl peroxide and topical sulphur creams. Retin-A can also be used during pregnancy as it is not sufficiently absorbed into the circulation to cause any problems. Certain oral antibiotics such as erythromycin are safe while the tetracycline should not be used. The latter can cause problems in the bony growth of the foetus during the second trimester. If tetracycline is accidentally taken in the first trimester there are no untoward consequences.
Ro-Accutane must never be used during pregnancy as it can cause major birth defects. If a woman has taken Ro-Accutane she should not get pregnant for at least one month after she has stopped taking the drug.
Acne may worsen during breast-feeding due to the substantial oestrogen level decrease. During this period, all topical anti-acne preparations can be used. Oral erythromycin is also safe, but other oral preparations should be avoided.
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HEADACHES: CAUSES, SIGNS AND DRUGS
A serious underlying disease, such as a brain tumor, may cause the headache in patients complaining of skull pains. Here are the warning signs of severe problems, as cited by Dr. Lipton:
? Sudden onset of the worst headache could mean you are bleeding in the brain – a stroke. Go immediately to the hospital emergency room.
? Headache with fever and a stiff neck could mean meningitis. The symptoms may signal bleeding into the brain.
? If strong headaches replace weak ones over weeks or months, see your physician.
? Red eyes or blurring vision with a headache point to glaucoma, high pressure in the eye. Untreated, you risk blindness.
? A seizure (a fit) or a new type of headache, at any age but particularly after 55, is a good reason to consult your doctor.
As scientists unravel the causes of various headaches, new treatments are being devised, though exactly why some of them work is often unclear.
Rodney Fritz, news director and morning anchor of WMJX-FM, a radio station in Boston, endured cluster headaches every August for 5 years. “The third year was the worst ever,” he says. “It was like someone sticking a hot poker in my eye. I would pace. I wore a path in the rug. Tears were coming from my eye.”
Mr. Fritz went to the headache center at Faulkner Hospital in Boston, where they gave him ergotamine and verapamil, a drug that lowers high blood pressure. They also gave him pure oxygen to breathe. The treatments helped ease his pain.
Dr. Egilius L. H. Spierings, director of the headache center at Faulkner, has tested verapamil on 48 cluster-headache patients and says two-thirds improved greatly.
Dr. Lipton categorizes headache drugs this way:
? Abortive – These stop headaches. They include ergotamine and some of the new non-steroidal anti-inflammatory chemicals.
? Prophylactic – These prevent headaches. They include antidepressants, beta-blockers, and calcium channel-blockers. These chemicals act on tiny muscles in the arteries. The last two usually are used to treat high blood pressure. Verapamil is a calcium channel-blocker. Chiefly used for cluster headaches are methysergide, prednisone (a type of cortisone), and lithium, a drug usually prescribed for manic depression.
? Symptomatic – These drugs reduce the pain and other headache symptoms. They include aspirin, codeine, and other painkillers. But sometimes these drugs make the headache worse. Should you get rebound headaches in the morning, your doctor might prescribe Compazine to reduce the nausea of migraine.
At the General Medical Center in Akron, Ohio, Dr. James Dougherty injected patients with Compazine. He says it stopped the cluster headaches without the aid of other painkillers.
Headaches also often respond to non-drug treatments, such as relaxation therapy, meditation, hypnosis, and biofeedback. If chronic stress on the job or at home triggers headaches, it may be important to change your job or adopt a new lifestyle. Psychological counseling may help.
By doing more research on the underlying causes, scientists quite possibly will find new and effective ways to stop, prevent, or ease the pain of headaches.
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WINNING AGAINST STROKE
A stroke happens so fast that the victim often recalls nothing about it. The brain simply does not have enough time to store the event in its memory banks. But the stroke’s damage is evident: There may be paralysis on one side of the body. Perhaps there is an inability to speak, indicating brain damage.
A stroke occurs when something shuts off the blood supply to brain cells. Deprived of the blood’s essential oxygen and nutrients, the cells die. The blood supply might be stopped when an artery is clogged by a clot, an air bubble, or solid tissue, or when an artery bursts, releasing blood that pools rather than circulates.
William Wylder, 73, a former radio and TV reporter, said his stroke terrified him. The symptoms he described are fairly typical: “In 1973,” he recalls, “with no warning symptoms before it happened, I had a stroke while I was doing a radio newscast in Rock Island, Illinois. It was the craziest newscast ever. I could not speak. I could not get anyone’s attention. My arms were flailing. I managed to crawl to my car. Somehow, I drove home, and my wife got me to the doctor.”
Each year, 500,000 or more Americans experience strokes. Two-thirds survive, many unable to support themselves or live productive lives. Three million U.S. residents have had at least one stroke, and $30 billion is spent for treatment and care each year.
Persons undergoing coronary bypass surgery also are at risk of stroke. A patient’s heart is slowed for the surgery. Because of this, there is an increased risk of blood clotting, and 5 to 7 percent of bypass surgery patients suffer strokes from clots that form during surgery.
“Of those patients who undergo bypass, 30 percent are not mentally as good as they were before surgery,” says Dr. Denise Barbut, director of the stroke center at New York Hospital in Manhattan. “We are trying to prevent that.”
Despite such grim statistics, progress in medication, technology, and research is brightening the picture.
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WHEN FIRST DIAGNOSED: UNDERSTANDING AND COMMUNICATING ABOUT
HIV-WHAT YOU NEED TO KNOW: WHO TO NOTIFY
People with HIV infection have an ethical and, in many places, a legal requirement to notify people they may have exposed to HIV. Those with HIV infection must also tell people with whom they are having the kind of contact that might transmit HIV. These are two of the hardest things someone with HIV infection has to do.
People with HIV infection are obliged to notify anyone they have exposed to the virus. This means anyone with whom they have had non-safe sex (that is, sex without a condom, or sex that involved exchange of body fluids) and with whom they have shared needles or works. This applies to past as well as present and future relationships.
For past relationships, the major problem is knowing how far back in time to go. Most people with HIV do not know when they acquired the infection. Since the infection may be silent for a long time, they may conceivably have been placing others at risk for several years. For practical purposes, most authorities recommend notifying all contacts for the past one or two years. This is the absolute minimum.
People who have been exposed should be notified and advised to take the test to find out if they are infected. They might also want to ask a physician about the probability of infection, the necessity for medical evaluation beyond simple testing for HIV, and the desirability of
subsequent testing. It may be at least somewhat reassuring to know that the virus is not easily transmitted. Studies of heterosexual couples show that the risk of infection is estimated to be less than 1 in 100 for a single sexual contact. The same studies show that, even for those who have had regular sexual contact over extended periods, the risk of infection is less than 50 percent. Similar studies have not yet been done for gay men; the risks are probably somewhat higher.
There are two reasons for notifying people you may have exposed to HIV. One is so they can obtain health care and counseling themselves; they will also need to take precautions not to spread the infection further. This is the only way, right now, that the epidemic can be controlled. The other reason for notification is that doing so is probably a legal requirement; depending on where you live, notification may be the law. Though legal requirements vary from state to state, most states now have laws that mandate notification.
Moreover, physicians may be obliged to notify anyone you do not notify. There is debate about this. On the one hand, the patient-physician relationship is privileged, or private. On the other, the physician has an obligation to society. A legal precedent was established with the case of Tarasoffv. Regents of the University of California, in which a psychologist who learned of a patient’s intent to murder a young woman was held liable for not taking appropriate steps to protect her. This decision established that the physician has what is called a “duty to warn” unsuspecting people who are engaged in behavior that puts them at risk. As a result, the physician will usually advise a patient to notify people who have been and continue to be placed at risk of infection. If the patient is unwilling to do this, the physician appears to have the authority and even the responsibility to do it, either directly or through public health authorities.
Notifying others of the possibility of HIV infection is extremely difficult. People who simply cannot do it are advised to discuss their concerns with their physicians. They might also benefit from consulting a psychiatrist or a psychologist, or by participating in support groups, or by talking to friends and relatives.
Those who remain unable to tell others directly might do it indirectly, through another individual such as a physician. An alternative is for the person or the physician to notify public health authorities, who will then make the necessary notification. Neither physicians nor public health authorities have to identify the source of their information. The person who may be exposed is simply told of the possibility of exposure without ever being told the specific source. Any of these alternatives is acceptable. The important thing is for the person exposed to be notified, tested, and counseled?and as soon as possible.
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MEDICATIONS: SIDE EFFECTS OF NSAIDs (NON-STEROIDAL ANTI-INFLAMMATORY DRUGS)
The most common side effects of NSAIDs are stomach upset. These symptoms are generally relieved by taking the medication with a meal or by adjusting the dosage.
Patients who have been taking NSAIDs for a long time can develop serious stomach problems (gastritis or stomach ulcer). Bleeding ulcers are an infrequent side effect of NSAID therapy. If gastritis, stomach ulcer, or bleeding ulcer develop, however, you will need to discontinue taking the NSAID and take medication that treats your stomach problem. Again, misoprostal helps prevent this side effect.
A less common side effect of NSAID therapy is kidney problems. Such problems are rare in healthy individuals, but some people have known risk factors for developing such problems. These include a previous history of kidney disease, diabetes, uncontrolled high blood pressure, age greater than sixty, significant liver disease, heart failure, and hardening of the arteries. Almost all kidney problems caused by NSAIDs resolve when the medication is discontinued.
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VARIETIES OF HEADACHES: MIGRAINE, TENSION HEADACHES
The word migraine stems from the Greek and Latin hemicranium, for “half a skull,” meaning that the pain keeps to one side of the head. Feeling pressure developing on one side of the head is the classic sign of the onset of a migraine headache. Other symptoms include vomiting or nausea, dizziness, and sensitivity to light.
Some migraineurs (the word for migraine sufferers) see spots, lines, or heat waves; some even experience a partial loss of vision before the onset of a headache.
Only 4 percent of reported headaches fall into the migraine category. Two to four times more women than men have migraines. These figures come from a study of 10,000 men and women in their teens and 20s conducted by Dr. Martha Linet and Walter F. Stewart, colleagues at the Johns Hopkins University School of Hygiene and Public Health in Baltimore.
More common are tension headaches. You suffer pains in the neck, shoulders, and the muscles near your skull – you can feel the tension in those muscles with your fingers. One group of scientists says that when these muscles contract in a spasm, you get a tension headache. Others have tried to measure the spasm without success. This kind of headache is relieved nicely by aspirin, acetaminophen, or other over-the-counter drugs called non-steroidal pain relievers.
A third kind of head pain comes from cluster headaches, which pop up in groups in the course of a day, week, or month. After a period of peace, they return. The pain of cluster headaches is so intense that, in rare cases, it has driven victims to seek relief by banging their skulls against walls.
Blair Hodowal, 35, is a supervisor in the highway department of Centerville City, Indiana. Five years ago, his cluster headaches began with one bad headache. “During the headaches, my eye would tear,” he recalls. “My teeth hurt like they had giant cavities. My nose ran. It would incapacitate me for a half hour. The pain is like jamming a knife into your head, and there is nothing that will make it quit. I would scream.”
In 1988, Mr. Hodowal found Dr. Ninan Mathew at the Houston Headache Clinic. Dr. Mathew, president of the American Association for the Study of Headache, recommended the use of radio frequency waves to deaden certain nerves.
“They numbed me from the top of my forehead to my upper teeth and to the back of my ear,” Mr. Hodowal says. “I can only eat on one side of my mouth. But it was worth it. I can now work and function. After the pain I’ve been through, this is heaven.”
In a test Dr. Mathew and Dr. Wayne Hurt have tried the procedure on 65 patients with chronic cluster headaches. Dr. Mathew reports that 75 percent responded excellently.
*2/266/5*

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Other names: Co-amoxiclav

SUFFERING FROM HEADACHES
Headaches come in many varieties – tension, migraine, and cluster are just three of them – and they merit many adjectives, such as splitting, as in, “I have a splitting headache.” Also aching, blinding, and terrible. Few people escape headaches in their lifetimes. In fact, the pain of headaches is so common that we often equate them with troublesome people or situations, which we refer to as “real headaches.”
Up until the last century, doctors could offer headache sufferers only mild relief, with such remedies as vapors or poultices of foul-smelling herbs and vinegars. Some of these “treatments” really worked. But, on the whole, if you had a headache, you had to wait it out – let it run its course – in pain.
All that has changed. Now very few headaches cannot be helped in some way, thanks to new discoveries about how headaches arise and new medicines that can ease the headache’s pain or even prevent its occurrence.
Practically everyone at one time has suffered a pain in the skull. The ache ranges from a passing pang to a full-blown explosion of agony that some experts say has even caused suicide. Each year, 42 million Americans drop what they are doing and search for relief from their pounding headaches. They visit their doctors 18 million times a year seeking respite.
Headaches occur more often than colds, more often than pain anywhere else in the body. They are the most common sickness signals, passing quickly with or without simple treatment. But if yours are intense and recur, do see your doctor without delay. They might be the first of headache torments to plague you week after week, year after year. Severe headaches interfere with normal work and social activities for perhaps 2 million Americans. Adults lose workdays, and children lose school days because of them.
There is no cure for most obstinately recurring headaches, of which migraines and cluster headaches are the most dreaded, but there is relief. Dr. Seymour Solomon, director of the nation’s first headache unit at Montefiore Medical Center in the Bronx, New York, says that doctors cannot eliminate the underlying causes of headaches. “But,” he adds, “80 percent of people who come to us with intractable headaches can be helped to lead a normal life. We cannot promise that they will never have another headache, but we can reduce the frequency and severity of the pain.”
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ASPIRIN THERAPY: SIDE EFFECTS AND CAUTIONARY NOTES
Side effects
The most common side effect of high-dose aspirin therapy is stomach distress. Symptoms are usually minor and can be relieved by taking aspirin with meals.
Another common side effect is blood passed in tiny amounts daily in the stool. This is usually not dangerous, but it can lead to anemia.
Some people on high-dose aspirin therapy develop serious stomach problems such as gastritis and stomach ulcer. Fortunately, bleeding ulcers are infrequent. Anyone developing one of these problems needs to stop taking aspirin and begin treatment with special stomach medications. The medication misoprostal (Cytotec) helps prevent these side effects.
Cautionary Notes
Before starting aspirin therapy discuss the following with your physician:
? A history of allergy to aspirin or other anti-inflammatory medications. Symptoms of allergy include rash, hives, and swollen lips or eyelids. Wheezing and difficulty with breathing are rare and serious allergic responses.
? A history of asthma, nasal polyps, stomach ulcer, bleeding problems, colitis, kidney or liver problems.
? Any medications that you are presently taking. Of particular importance are blood thinners, diabetes medication, blood pressure pills, seizure medication, and over-the-counter pain medications.
While taking aspirin:
? Contact your physician promptly if you notice dark or tar-colored bowel movements, persistent indigestion or nausea, stomach pain that is relieved by eating.
? Never take more than one anti-inflammatory drug at a time. If your doctor prescribes a new NSAID, he or she will almost certainly take you off aspirin; if he or she fails to discuss this with you, you should ask about it. Do not take over-the-counter anti-inflammatory medications such as ibuprofen while you are taking high doses of aspirin. If your physician approves, acetaminophen (Tylenol) may be taken while you are taking aspirin. Unless you are instructed otherwise, you should take aspirin at mealtime to reduce indigestion and stomach irritation.
? Inform your dentist, surgeon, and anyone else performing health care procedures that you are on aspirin therapy.
? Avoid drinking alcohol and smoking because these practices increase your risk of developing an ulcer.
? Your doctor may periodically request blood tests for blood cell counts, kidney and liver tests, and tests for electrolytes (sodium and potassium) levels, as well as examine your stool for blood.
Pregnancy and breastfeeding. Aspirin should be avoided during pregnancy, particularly during the last trimester, unless specifically prescribed by your doctor. Aspirin therapy may affect the fetus or cause complications during labor and delivery.
Salicylates are excreted in breast milk, and therefore large doses of aspirin should be avoided while nursing.
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