Ennio Morricone's Nella Fantasia

Music As Medication

An interesting article by David Was from National Public Radio.

http://www.npr.org/templates/story/story.php?storyId=120768762

Autumn by Vivaldi

H1N1 (Swine) Flu Update

A California study of H1N1 influenza, reported in Nov. 4 JAMA (Journal of the American Medical Association), showed that this strain seems to affect younger and obese patients. The median age was 27 years. Of 268 adults aged 20 years or older, 58% was obese (body mass index >30.)

Among studied patients, 11% died. The most common causes of death were viral pneumonia and acute respiratory distress syndrome.

Authors of the study recommended doctors give antiviral treatment to all hospitalized patients with 2009 H1N1 infection as soon as possible, regardless of when symptoms start.

Shostakovich's Second Waltz by Andre Rieu

Exercise and Health

A retrospective study analyzing physical activities of 10,269 Harvard alumni over 12 years showed that men who engaged in vigorous sports had a 23 percent lower risk of death than those who did not. Vigorous sports were defined as brisk walking, cycling, swimming, and yard work for 30 minutes a day on most days.

The Health Professionals' Follow-up Study evaluated the relationship between intensity of exercise and cardiovascular benefit in 44,452 men. The study found several types of sports that would result in a significant reduction in risk of coronary heart disease. The studied sport activities were:

• Running for one hour or more per week
• Brisk walking for 30 minutes or more per day
• Lifting weight for 30 minutes or more per week
• Rowing for one hour or more per week

Somewhere My Love by Ray Conniff

Hepatitis A

Hepatitis A (HAV) is spread via fecal-oral route. It is more common in areas where there is poor hygien. The most common risk factors are:

• Travel to Mexico, South America, Africa, Asia
• Contact with people inflicted with HAV
• Food-borne outbreaks
• Daycare center
• Injection drug use

HAV causes injury to liver where human immune system fights against viruses that hide inside liver cells, a.k.a hepatocytes. Fierce battles can result in severe hepatitis which typically presents with jaundice (yellowish discoloration of skin, eyes) and enlarged liver. Your doctors may want to confirm the diagnosis by way of blood tests such as ALT, AST, bilirubin, alkaline phosphatase, and anti-HAV IgM antibody.

The good news is that HAV is a self-limited condition: 85 percent of cases have full recovery within 3 months, and nearly 100 percent have complete recovery by 6 months.

HAV, however, can be fatal in those who have concurrent chronic hepatitis C. These individuals die of fulminant hepatic failure.

Prevention involves handwashing, avoidance of water and foods from endemic areas.

HAV vaccines also are available.

Chan Chan by Buena Vista Social Club

My favorite Cuban music band, Buena Vista Social Club.

Swine Flu Update

Electron micrscope image of H1N1 virus

I recently witnessed 2 cases of swine (H1N1) flu that resulted in different outcomes. Both patients were of about same age, 40 and 41. The younger patient smoked cigarettes and likely had underlying lung disease; the other did not. Both were admitted to a hospital on the same day. Both had high fever. The smoking patient had to be intubated and be placed on ventilator shortly after her admission. The non-smoking one managed to get by. Initial rapid flu tests were negative for both patients. Oropharyngeal PCR tests, however, were positive for both. Three days later the smoking patient died, but the non-smoking one was discharged home in stable condition.

Center for Disease Control recently evaluated rapid flu tests, also known as screening tests, and found that these tests had low sensitivity (40%-69%). Low sensitivity means a negative test shows no H1N1 virus only in 40% to 69% of tested patients. As a result, WHO recommends antiviral medications such as Tamiflu be considered for patients with higher risks such as pregnancy, pneumonia, rapid progression to respiratory distress, or other underlying diseases. Meanwhile, PCR assay test should be used to make a definitive diagnosis. The disadvantage of PCR test is that it takes longer, usually 2-3 days in the US, to obtain final result.

Paris Musette by Paul Mauriat

Obesity and Soaring Health Care Cost in the US

According to research group RTI International, Americans whose weight is 30 or more pounds over a healthy weight cost the U.S. an estimated $147 billion in medical bills in 2008. Obesity now accounts for 9.1% of all medical spending. An obese patient incurs on average $4,871 in medical bills a year compared with $3,442 for a patient of healthy weight. Obese patients spend $600 more in prescription medications a year than patients of healthy weight.

About 34% of adult Americans were obese in 2006.

"Obesity is the single biggest reason for the increase in health care costs," says Eric Finkelstein, a health economist with RTI.

Meditation from Thais: Violin vs Cello

Violin by Marina Chiche






Cello by Yo Yo Ma

Wine, Your Heart, and Resveratrol

Wine drinking in moderation may beneficial to coronary heart disease. Current recommendations for safe drinking of alcohol are one drink a day for women and no more than two drinks a day for men. These recommendations are difficult to quantify since the definition of "one drink" may differ among individuals. For example, one person may think a 4-ounce (equivalent to about 120 ml) glass as one drink while another considers an 8-ounce (equivalent to about 240 ml) glass as one drink. Therefore, one needs a better quantitation. Fortunately, several studies have suggested that the ideal dose of alcohol is around 6 grams (approximately 600 ml) per day.

Resveratrol is a substance found in grape skin and red wine. Resveratrol supplements are being marketed as to improve metabolism and lifespan. The benefits of reseratrol, however, was observed only in mice. Current resveratrol supplements do not have standardized dosage and side effects are unknown. Therefore, these supplements are currently not recommended.

Million Roses by Alla Pugacheva

Lung Cancer in Non-Smokers and Women

Although lung cancer has a clear causative relationship with cigarette smoking, it can also occurs in individuals who never smoke or smoke very lightly. Interestingly, lung cancer among non-smokers is higher among women than men. In the US, 19 percent of lung cancer in women occurs in non-smokers, compared to 9 percent in men. In Asia, 60 to 80 percent of women with lung cancer never smoke [Nat Rev Cancer. 2007 Oct;7(10):778-90].

Adenocarcinoma, a subtype of lung cancer, is more common in non-smokers or light smokers.

The risk factors of lung cancer in non-smokers are:

• Secondhand smoke


• Radon


• Asbestos


• Burning coal smoke or indoor cooking oil vapor that is very common in Asia
  

Molecular biology of lung cancer in non-smokers is different from that of cancer in smokers. It has been observed that mutations of the epidermal growth factor receptor (EGFR) are more common in lung cancers in non-smokers. Therefore, current treatment of lung cancer in non-smokers is skewed toward the use of medications that inhibit EGFR tyrosine kinase.

Summer by Vivaldi

Knee and Osteoarthritis (OA)

The knee is the largest human joint and has the greatest susceptibility to injury, wear and tear.

Osteoarthritis (OA), a failure of cartilage of joints, commonly affects knees. OA is no longer considered a problem of advanced aging. OA results from a complex interaction among genetics, metabolism, inflammation and mechanical factors.
Knee OA has a very strong association with obesity.

Knee joint consists of bony ends, cartilage, ligaments, and synovial fluid.






As you can see, the meniscal cartilage is sandwiched between tibia and femur. These menisci help absorb impact that is related to weight-bearing activities. The anterior and posterior cruciate ligaments help prevent knee bones from moving too much forwards or backwards.

Knee pain is the most common complaint among those who have knee OA. Knee pain can occur on inner side (medial pain), outer side (lateral pain), front side (anterior pain), or back side (popliteal pain) of the knee. Medial pain is the most common complaint of knee pain because the medial compartment of the knee has the greatest susceptibility to age-related wear and tear.

Doctors usually diagnose knee OA if patients complain of knee pain and also have at least three of the following six features:

• Age of over 50


• Morning stiffness for less than 30 minutes


• Knee bone tenderness


• Knee bone enlargement


• Clicking or grinding sound of knee bones on movements


• Absence of warm knee

Doctors may order knee X-rays to ascertain the diagnosis of OA or to rule out other knee diseases.

To treat knee OA, doctors usually start with recommendation for short-lived rest, braces, exercise, weight loss. Pain medications, needle aspiration, joint injection are next steps. Many patients may eventually need surgery. Supplements such as glucosamine and chondroitin might help but their benefits have not been proven.

Canon in D Major by Pachelbel

Swine Flu

Flu virus

Flu, also known as Influenza, is an acute respiratory infection that is caused by influenza A or B viruses. Flu usually occurs in outbreaks. If the extent of flu outbreak is larger, health care organizations such as Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) may call it epidemic or pandemic.

Swine flu is caused by type A influenza virus that usually causes outbreaks in pigs. Nonetheless, there is recent evidence that swine flu transmits from person to person. However, you cannot catch swine flu by eating cooked pork.

Flu infection is transmitted through coughing, sneezing since large amounts of virus are present in respiratory secretions.

Flu outbreak usually occurs in winter. Prominent symptoms of flu are fever, muscle ache, headache, coughing, weakness.

Flu is usually self-limited, gradually improving over 2 to 5 days. Flu, however, may result in complications. Common complications of flu are pneumonia, and myositis that is associated with extreme tenderness of legs. Guillain-Barre syndrome, an acute inflammation of multiple nerves, is also suspected to be a complication of flu; but a definite causal relationship has not been established.

Doctors usually diagnose flu based on symptoms, signs, the existence of outbreaks. They may also order throat, nasal swabs, or Quick Vue A+B tests.

Doctors may prescribe Oseltamivir or Zanamivir to alleviate flu symptoms, to help you recover faster, or to prevent flu.

You may be able to find more information about swine flu at following CDC link.
http://www.cdc.gov/swineflu/swineflu_you.htm

Scarborough Fair by Sarah Brightman

Prevention of Running Leg Injuries

Running helps to promote healthy heart, reduce obesity and osteoporosis. Running also helps enhance mental health. Running, however, also increases risk of injuries to hips, knees and feet. Most of running injuries are insidious and are not neccessarily associated with specific trauma.

There are several things you should do or not do to prevent leg injuries.

Do:

• Stretch before and after running: even though a meta-analysis study by the US Centers for Disease Control and Prevention was inconclusive as to the real benefit of routine stretching, many runners have found it helpful
• Make sure shoes are fitting every time you buy new pairs since feet widens with age
• Change running shoes every 350 to 500 miles since new shoes lose 40 percent of cushioning after that much distance
• Use orthoses if you have excessive pronation, patellofemoral pain, plantar fasciitis, shin splints, or Achilles tendinitis
• Use ankle braces if you have prior ankle injuries
• Rest completely from running during injuries

Don't:

• Run persistently 40 miles or more per week since it is the most important risk of injury.

The Last of the Mohicans by Hans Zimmer

Septic Lateral Sinus Thrombosis

Septic Lateral Sinus Thrombosis (SLST) is associated with mastoiditis, which is a complication of otitis media. Inflicted patients usually have following symptoms for several weeks before diagnosis is made.

• Fever
• Headache on the side of the ear infection
• Nausea and/or vomitting
• Vertigo
• Photophobia (fear and avoidance of lighting)
• Neck stiffness

Doctors usually suspect SLST when they see evidence of otitis media, along with the swelling of the area that is immediately behind the affected outer ear. The existence of sixth nerve dysfunction even raises strong suspicion of SLST. An MRI will help make the diagnosis of SLST.

MRI shows lateral sinus thrombosis on the left side

Initial treatment requires immediate IV antibiotic therapy that is a combination of ceftriaxone, metronidazole, and vancomycin. Doctors may adjust antibiotics in accordance with other available laboratory results.

If inflicted patients still have fever within 12-24 hours following the initiation of appropriate antibiotics, doctors usually proceed with radical mastoidectomy with drainage of pus and infected fluid.

Dust in the Wind by Kansas

Acute Otitis Media

Acute Otitis Media (AOM) refers to the presence of fluid in the middle ear and symptoms or signs of inflammation must be present in inflicted patients. Although AOM may occur at any ages, it is in the U.S most commonly seen in infants aged between 6 and 24 months. Established risk factors are as follows:

• Daycare: Children attending daycare centers have been shown to have higher incidence of AOM [Int J Pediatr Otorhinolaryngol 2000 Sep 15;55(1):33-45]
  
• Pacifier use: Children who use a pacifier have higher incidence of AOM
  
• Tobacco smoke
  
• Air pollution
  
• Family history

Breast feeding for 3 months or longer has been shown to decrease episodes of AOM [Clin Infect Dis 1996 Jun;22(6):1079-83].

The congestion of the inner lining, a.k.a. mucosa, of the eustachian tube, a.k.a. ear tube, precedes AOM. This congestion causes obstruction of the ear tube. The obstruction results in accumulation of secretions in the middle ear where viruses and bacteria grow and cause AOM. The middle ear secretions may persist for weeks following AOM.

To diagnose AOM, doctors use a pneumatic otoscope.

Normal ear drum

Ear drum in acute otitis media

Complications of AOM such as mastoiditis and meningitis occur more often in developing countries. Other important complications are labyrinthitis, petrositis, and lateral sinus thrombosis.

You Got It by Roy Orbison

Doctor's Day

Medical Doctors are those who are there to deliver your babies when you are in labor, to help you when you are ill, and to keep you well when you are well. Many countries recognize doctors' contributions to society by designating a Doctor's Day: It is July 1 in India, February 27 in Viet Nam.

"The Doctor" by Luke Fildes

In the U.S., National Doctor's Day always falls on March 30th. National Doctor's Day observance dates back to 30 March 1933 when it was first conceived by Eudora Brown Almond of Winder, Georgia. The day marks the anniversary of the first use of general anesthesia that occured in 1842. The U.S. House of Representatives adopted a resolution commemorating Doctor's Day on 30 March 1958. National Doctor's Day was, however, not established until March 30, 1990 when President Bush signed the resolution into law. The first Doctor's Day was celebrated nationwide in the U.S. on March 30, 1991.

Sounds of Silence by Simon and Garfunkel

Pleural Empyema

Pleural spaces are seen as black, curving lines wrapping around lungs

Pleural empyema refers to the infection of pleural space, which is located between two lining sheets that wrap around lungs. In healthy people, this pleural space is deflated and does not contain fluid. This space, however, may expand and contain abnormal fluid which usually leaks in from infected or injured lungs. If pus or bacteria are found in this abnormal fluid, pleural empyema is diagnosed.

Arrows point at pleural empyema seen on a chest CT scan

Pleural empyema can become deadly if left untreated.

Treatment requires the placement of a chest tube which helps drain pus or infected fluid. Also, 4-6 weeks of antibiotics that help kill both aerobes and anaerobes are required.

In some cases empyema walls become thickened scars that prevent lungs from expanding properly, even after infection is successfully treated. These conditions are called "trapped lungs" and treating doctors may recommend decortication.

Gitano Soy by Gipsy Kings

Quinsy

Quinsy, or peritonsillar abscess, refers to a complication of tonsilitis. George Washington is believed to have died of complications of quinsy.

Patients with quinsy usually have fever, sore throat, muffled voice. Many cannot swallow or open mouth. Quinsy usually affects only one side of the throat.

Quinsy on the right side of throat

Left untreated, quinsy may result in more serious complications such as airway obstruction, rupture of abscess. Rupture of abscess results in the accumulation of pus in a space that surrounds the throat. This complication can be lethal.

Quinsy must be drained. Intraveous antibiotics are also required. Doctors usually prescribe ampicillin-sulbactam, a combination of penicillin G and metronidazole, or clindamycin.

Now We Are Free

Swimmer's Ear

Swimmer's ear refers to the inflammation of ear canal in those who swim and usually live in humid tropical regions. Swimmer's ear is just one of inflammatory diseases of ear canal, also known as external otitis or otitis externa.

Those who wear hearing aids, headphones have higher risk of external otitis. People who use cotton swabs to clean cerumen excessively also have increased risk since cotton swabs can create abrasions in the ear canal skin, making it easy for bacteria to invade deeper tissue.

The most common bacteria responsible for external otitis are Pseudomonas aeruginosa, Staphyloccocus aureus, bacteroides, and peptostreptococci. Fungi account for about 2 to 10 percent of cases of otitis externa and usually cause infection following the treatment of bacterial infection.

The most common symptoms of external otitis are ear-ache, itch, ear discharge, and hearing loss.

Treatment of external otitis usually requires thorough cleaning of the ear canal, use of topical antibiotics, and pain control. Ear canal cleaning is the most important step and should be performed at doctors' offices.

Cristofori's Dream by David Lanz

Larynx, Vocal Cords, and Hoarseness

Normal Larynx

Larynx, also known as voice box, connects throat with trachea. Within the larynx lie vocal cords, which dictate your vocal tone or phonation. Larynx also works in sync with epiglottis to prevents food from going into your trachea and lungs.


Vocal tone results from the vibration of vocal cords as air comes out through them. An illustration of how vocal cords produce sound is as below.



The frequency of vibration determines the vocal pitch as heard by ears. The usual frequency during normal speech ranges from 100 to 300 times per second (Hz). Soprano singers' frequency can be greater than 1000 Hz. The above vocal pitch is probably not the best ear-pleasing sound you have ever heard. Many singers, however, are able to produce fantastic sound. An example of Sarah Brightman's soprano is as below.



Hoarseness refers to any change in voice that indicates injuries to larynx or vocal cords. These injuries may be due to inflammation, infection, tumor, or neurological diseases.

If you smoke cigarettes or drink excess alcohol, your hoarseness usually indicates the inflammation of larynx, also known as laryngitis. Hoarseness that lasts for more than 2 weeks, however, requires a complete examination to rule out laryngeal cancer.

What A Wonderful World by Louis Armstrong

Chronic Sinusitis

Chronic rhinosinusitis is a group of different diseases that affect nasal mucosa and paranasal sinuses. These diseases last 12 weeks or longer, in spite of medical treatment.

Chronic sinusitis is divided into 3 syndromes since treatments are different. The 3 syndromes are:

1. Chronic sinusitis without nasal polyps which accounts for about 65 percent of cases


2. Chronic sinusitis with nasal polyps which account for about 25 percent


3. Allergic fungal sinusitis which accounts for about 10 percent

Those who are inflicted with chronic sinusitis must have at least 2 of the following 4 symptoms:

1. Yellow or greenish runny nose
2. Facial pain or pressure
3. Stuffy nose or nasal obstruction
4. Diminished sense of smell

CT scans of sinuses are usually required to make an accurate diagnosis (see picture).

Treatment of chronic sinusitis usually involves multiple therapies, most of which have not been validated in randomized trials. In most cases, the goal of treatment is to alleviate symptoms since chronic sinusitis may not be cured.

Greenfield by The Brothers Four

Acute Sinusitis

Sinusitis, also known as rhinosinusitis, is commonly caused by viruses. Viruses initially infect nasal mucosa then spread to paranasal sinuses (see picture). Interestingly, nose blowing may propel infected nasal fluid into sinuses.

In 0.5 to 2 percent of viral sinusitis cases, bacteria impose more complicated infection. The most common bacteria are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. It may be difficult to tell viral from bacterial sinusitis, since existing clinical criteria are not reliable. Abnormal vision, swelling of eyes, or confusion are worrisome symptoms that require urgent referral to specialists.

Sinus CT scan is not helpful in differentiating between viral and bacterial sinusitis. CT may help exclude diagnosis of sinusitis if there are no evidence of edema or gaseous bubbles. Sinus CT should be done without contrast.

Antibiotics are indicated for bacterial sinusitis, but not recommended for viral cases.

Vivo Per Lei by Andrea Bocelli

Body Mass Index (BMI) and Obesity

Obesity has been associated with at least 15 well-known health problems and been documented in medical literature for at least 2000 years. The Framingham Study concluded that those who were obese at age 40 lived 6 to 7 years less than those who were not [Ann Intern Med 2003 Jan 7;138(1):24-32].

In Japan, people over 40 have to undergo waistline measurement to see if they are too fat or not. Those who are deemed too fat have to go through diet counseling. If chubby Japanese fail to get slender, they may be fined.

New Zealanders go even more extreme: Goverment can restrict those who are deemed "too fat" from immigrating to the country. It is unclear, however, which criteria New Zealand goverment uses to determine a "fat" individual from "non-fat" one .

In the U.S., obesity is a big public health problem. Data from the National Health and Nutrition Examination Survey 1999-2000 shows that the prevalence of overweight and obesity in adults is 64.5 percent and 30.5 percent, respectively. Even though there is no fine or immigration restriction policy yet in the U.S., life-style changes and weight-loss treatment are recommended for men and women whose waistlines are greater than 40 inches (102 cm) and 35 inches (89 cm), respectively.

The body mass index (BMI) is used to evaluate obesity. Overweight is defined as a BMI between 25 and 30; obesity between 30 and 35; morbid obesity greater than 35.

If you are curious about where you stand in the BMI spectrum, you may want to use the calculator located in the lower right-sided corner of vietshealth blog home page.

Passacaglia by Secret Garden

Pancreatic Cancer

Actor Patrick Swayze, a famous pancreatic cancer patient.

Pancreatic cancer is insidious, often dubbed as "silent killer." It is difficult to treat since a majority of patients have advanced tumors by the time they tell doctors symptoms. It is interesting to know that atypical diabetes mellitus, glucose intolerance occuring in a thin older adult, precedes pancreatic cancer in many cases [Gastroenterology 2005 Aug;129(2): 504-11].

Common symptoms of pancreatic cancer are poor appetite, weight loss, bloating abdomen or abdominal pain, jaundice (yellow skin), change in color of stool.

When a patient presents with suspicious symptoms, a doctor may recommend a variety of diagnostic studies such as ultrasound, CT scan, ERCP, MRCP, endoscopic ultrasound (EUS), serum tumor marker CA 19-9. Staging laparascopy is also used to determine whether a tumor is resectable.

When a suspicious pancreatic tumor is seen on scan or ultrasound, doctors may recommend resection before an absolute diagnosis of cancer is established. However, some resected tumors may turn out benign, as in the case of U.S. Supreme Court Justice Ginsburg.

Surgical resection is the only curative treatment. However, only 15 to 20 percent of patients are candidates for surgery. The prognosis is poor even in patients with resectable cancer: the 5-year survival following surgery is about 10 to 30 percent. The use of adjuvant chemotherapy and radiotherapy may help some patients live longer after tumors are resected.

This Is What I Call Romance

Happy Valentine's Day!

Screening for Coronary Heart Disease (CHD)

Coronary Heart Disease (CHD) refers to a spectrum of heart diseases that result from damaged arteries of the heart. Angina pectoris (a.k.a. cardiac chest pain), unstable angina, ischemic heart disease, ischemic cardiomyopthy, and myocardial infarction (a.k.a. heart attack) are common variants of CHD. Atherosclerosis is a main cause of CHD.

CHD remains the leading cause of death in adults; many patient had sudden death as very first clinical symptom. A Framingham Heart Study concluded that lifetime risk of CHD for men and women aged 40 was 49% and 32% respectively. These men and women did not have any CHD at the beginning of this study [Lancet 1999 Jan 9;353(9147):89-92].

Since CHD may already exist in many individuals who do not have any symptoms, there is great interest in detecting this disease at its early stages, a.k.a. screening. There are various recommendations from different groups of experts with regard to CHD screening. Even though there is no unanimous consensus on it, asymptomatic people with high risks of CHD will benefit from screening. High risks of CHD are:

• Cigarette smoking


• Diabetes mellitus


• Cholesterol > 250mg/dl


• Systolic blood pressure > 140mmHg or diastolic blood pressure > 90 mmHg


• Family members who have heart attacks or die of sudden cardiac death under age 60
  

There exist several screening tests, none of which is perfect. Considering cost and easy accessibility, exercise ECG test is likely the best one.

Prelude in E Minor by Chopin

Lay back.
Close your eyes.
Imagine a person you love dearly.





How do you feel?

Atherosclerosis

Atherosclerosis is a medical term that describes the hardening of arterial wall, which is normally distensible and elastic. In other words, the wall of arteries become thicker and harder as atherosclerosis goes on. Atherosclerosis may eventually cause complete blockage of arteries, resulting in lack of blood supply to human organs. If the blockage affects the arteries of heart and brain, it will cause heart attacks and stroke, respectively.

Atherosclerosis begins in childhood and advances with aging. Atherosclerosis starts with the damage of the innermost lining of artery, also known as endothelial dysfunction. Then fat is deposited and accumulated at the damaged site, resulting in thickening of arterial wall. Bad fat, also known as low density lipid (LDL), accelerates thickening process to form a fibrous plaque. Fibrous plaque is a chunk of fat, tiny smooth muscle cells, and tiny fragile blood vessels. At some point in time, this plaque ruptures, causing blood clots that clog up the artery. Heart attacks or stroke will ensue.

There is convincing evidence that family history of coronary heart disease and cigarette smoking accelerate atherosclerosis.

In short, atherosclerosis is more severe if a person:

• has a family history of coronary heart disease
• eats bad fat such as saturated fat, trans-fat
• smokes cigarette

Wild Child by Enya

Mitral Stenosis (MS)

Mitral valve stenosis (MS) occurs when the leaflets of the mitral valve become thick and obstruct blood flow from the left atrium to the left ventricle of the heart. MS mostly results from rheumatic fever. MS may stay silent for 15 to 40 years after rheumatic fever until the onset of heart symptoms.

The area of the opening of a normal mitral valve is 4 to 6 cm2. Shortness of breath during physical activities usually occurs when the valve area is at least less than 2.5 cm2. Shortness of breath at rest occurs when the valve area is less than 1.5 cm2.

MS may cause several major complications as follows:

• Atrial fibrillation: an irregularly irregular heart rhythm in about 45 percent of cases


• Thromboembolism: blood clots thrown into other organs such as brain and lungs


• Bacterial endocarditis: an infection of mitral valve by bacteria traveling from other organs

Pregnant women with MS may have more severe symptoms and complications, especially heart failure.

Doctors may offer to treat MS with medications or surgical intervention when indicated. The 2006 American College of Cardiology/American Heart Association (ACC/AHA) and the 2007 European Society of Cardiology (ESC) guidelines concluded that main indications for intervention were moderate-to-severe MS and the presence of symptoms. Surgical options are percutaneous mitral balloon valvotomy (PMBV), commissurotomy, and mitral valve replacement.

The 2007 AHA guidelines did not recommend antibiotic prophylaxis for patients with MS before dental or invasive procedures.

Caravan by Kitaro

Aortic Stenosis (AS)

Aortic valve is a heart valve that controls the blood flow between left ventricle and aorta. Aortic stenosis occurs when valve leaflets become deformed, thus obstructing blood flow to other organs including the heart itself. Rheumatic heart disease is the most common cause of aortic stenosis (AS) in developing countries. In developed countries, an old aortic valve with built-up calcification is the most common cause of AS.

Aortic stenosis is severe when the calculated area of the valve is less than 1cm2. The measurment of the valve area is performed indirectly by measuring the blood flow and pressure gradient across the valve. Doctors usually recommend either echocardiography or cardiac catheterization to measure the area of valve, depending on whether the pumping power of left ventricle is normal or weak.

Patients with severe AS are considered candidates for valve replacement operation if they develop chest pain, pass-out, or heart failure. However, the 2006 American Heart Association (AHA) guidelines concluded that valve replacement should not be performed routinely in patients without aforementioned symptoms. There are exceptions when surgery is still recommended in patients without symptoms.

The 2007 AHA guidelines no longer recommended routine antibiotic prophylaxis before dental or invasive procedures for patients with AS.

Toccata by Paul Mariat & Orchestra

Diet and Your Heart

The following food and supplements are proven effective in preserving health of your heart.

1. Fruits and vegetables: green leafy vegetables, citrus fruits




2. High-fiber food




3. Unsaturated fat: olive and canola oil




4. Folate: 400 micrograms a day

Deliver Me by Sarah Brightman

Aortic Regurgitation (AR)

Aortic regurgitation (AR) occurs when aortic valve leaflets do not close adequately. As a result, blood flow leaks back to left ventricle (LV) which is one of the four heart chambers (see picture).

In developed countries, the most common causes of AR are aortic root dilation and congenital bicuspid aortic valve. In developing countries, the most common cause is rheumatic heart disease.

Since the size and function of left ventricle (LV) is critical in determining the timing and need for surgery, doctors may recommend serial echocardiography ranging from every 6 months to every 3 years.

The American Heart Association recommended aortic valve replacement or repair in asymptomatic patients with left ventricle pumping power (LVEF) <50>

With regard to medications, ACE inhibitor shows greatest benefit in patients with shortness of breath and significant dilation of left ventricle.

Women have a poorer outcome following aortic valve replacement when compared to men; post-operative 10-year survival rate for women and men was 39 and 72 percent respectively [Circulation 1996 Nov 15;94(10):2472-8].

The 2007 American Heart Association guidelines did not recommend antibiotic prophylaxis for patients with (AR) when they had dental or surgical procedures.

Yo Yo Ma plays Ennio Morricone

Mitral Regurgitation (MR)

Mitral regurgitation refers to the leakage of mitral valve, which is a heart valve that controls blood flow between left atrium and left ventricle (see picture).




The main causes of mitral regurgitation (MR) are mitral valve prolapse and rheumatic heart disease. Dilated heart chambers resulting from heart attacks also cause MR.

In principle, corrective surgery should be performed before left ventricular (LV) chamber becomes dysfunctional and fails. Patients usually do not recover well after surgery if the contractile power of left chamber (LVEF) is < 40 percent before surgery. Therefore, doctors may recommend periodical echocardiography to assess left ventricular chamber and determine the need and timing of surgery.

If surgery is not indicated, many patients may benefits from several heart medications, especially hydralazine.

MR is often associated with atrial fibrillation, an irregularly irregular hear rhythm, which can result in formation of blood clots. Doctors may recommend conversion to normal heart rhythm or blood thinners to prevent risk of stroke.

According to 2007 guidelines by American Heart Association, patients with MR may not need antibiotic prophylaxis before dental or surgical procedures. However, those patients with artificial mitral valve still need antibiotic prophylaxis.

Spring by Vivaldi

Mitral Valve Prolapse Syndrome

Mitral valve prolapse syndrome (MVPS) refers to a group of symptoms:

• Palpitations



• Anxiety



• Hyperventilation, i.e. rapid breathing



• Chest pain



• Easy fatigue



• Numbness



• Dizziness
  

It is interesting to know that these symptoms may occur both in patients with MVP and in those without it.

To alleviate these symptoms, you should:

• avoid stimulants such as caffeine, alcohol



• avoid fatigue



• reduce stress



• do aerobic exercise 3 times a week for 12 weeks

It is important that you change your lifestyle little by little and consistenly. Give yourself several weeks. Get positive feedbacks and encouragement from spouses, friends, or support groups.

Taking appropriate supplements or medications can help. MVP patients with low serum magnesium may benefit from taking magnesium supplements for 5 weeks. Those with anxiety, panic attack, or depression should consult their physicians for appropriate treatments.

The Storm by Yanni & Multinational Musicians

Mitral Valve Prolapse (MVP)

An old classmate was recently inflicted with cardiovascular conditions. Valentine's Day is also coming up. So, I've decided to post updated information about some common heart diseases.


Mitral valve prolapse (MVP) refers to an abnormal anatomy of one of heart valves: the mitral valve. In MVP, one or both mitral valve leaflets billow into the left atrium of the heart.

Prevalence of MVP is 2.4 percent in both men and women, and is evenly distributed among age groups[N Engl J Med 1999 Jul 1;341(1):1-7].

Although MVP is usually benign, it can cause more serious problems such as mitral regurgitation, infective endocarditis, and arrhythmias. Mitral regurgitation (MR) requires more medical attention.

It's always a good idea to see a doctor to make sure mitral valve prolapse does not evolve into mitral regurgitation.

Chuc Mung Nam Moi

Old Drug, New Trick

Sometimes old drug, like the case of aspirin, may be rejuvenated to help prevent another illness. Steven Shoelson, a Harvard researcher, postulates that inflammation contributes to the formation of diabetes mellitus. He also found in the basement of Harvard library a German medical article, published in 1876, that suggested salsalate, a medication similar to aspirin, might improve diabetics' ability to control blood sugar. He has since then worked with his colleagues on several studies that showed promising therapeutic effect of salsalate on diabetes mellitus. Now the National Institutes of Health is funding an ongoing large study to validate earlier results.



If Steven Shoelson is right, then diabetics would have a cheap ammunition to fight this costly disease.

Bach's Suite No.1 by Yo Yo Ma

Cigarettes & Your Health

There are still about 1.3 billion people smoking cigarette worldwide. Cigarette smoking is known to increase risks of chronic obstructive lung disease (COPD), lung cancer, and heart attack.

It is interesting that many smokers do not believe smoking is harmful. A study by the Department of Medicine, Harvard Medical School discovered even those who smoked more than 40 cigarettes a day did not believe that cigarettes increased risk for heart attack and cancer. Non-believers tend to be older (65 year or older), less educated (not a high school graduate), and smoking lighter (less than 20 cigarettes a day).

Adagio by Secret Garden

Drugs and Liver

Drug-induced liver injury (DILI) is a common liver disease. DILI is the cause of acute jaundice, which is yellow discoloration of eyes or skin, in up to 50 percent of patients. DILI accounts for up to 30 percent of acute hepatitis. Even in the U.S., where the use and distribution of prescription drugs are highly regulated, DILI is still the most common cause of acute liver failure. It is perceivable that the incidence of DILI may be much higher in countries where drugs can be purchased from pharmacies without doctors' approval.

Chinese herbal remedies are widely used in many countries. Many herbs have beneficial effects. However, DILI has been reported with at least 10 herbal species. Jin Bu Huan and Sy0-saiko-to are the most notorious products. It is ironic that Syo-saiko-to is used to supposedly treat hepatitis C virus infection; but there have been reports of DILI associated with this product [Dig Dis Sci 1995 Aug;40(8):1845-8].

Liver damage seen in a 24 year-old woman who took Jin Bu Huan for 2 months

The main treatment of DILI is withdrawal of offending drugs.

Only two specific therapies are proven beneficial in treating two specific DILI. These two therapies are:

1. N-acetylcysteine for acetaminophen toxicity
   
2. L-carnitine for valproic acide toxicity

Aqua by Kitaro

Alcohol & Hepatitis C

Chronic hepatitis C and alcohol are the two common causes of liver diseases worldwide. There is good evidence that they work together to speed up the progression of chronic liver disease. It is reported that the prevalence of hepatitis C is higher in alcoholics than in general population. The reason for this higher prevalence is not completely understood.

Several studies have observed that heavy alcohol use in patients with hepatitis C:

• decreases the efficacy of treatment of hepatitis C


• increases the risk of hepatocellular carcinoma, i.e. liver cancer


• increases the rate of deaths

Microscopic picture of a liver infected by hepatitis C viruses

A safe amount of alcohol consumption in patients with hepatitis C is not known. Therefore, those who are inflicted with hepatitis C should completely abstain from alcohol.

Nocturne by Secret Garden

Colon Cancer & Diet

At this time, it is still unclear whether high-fiber diet reduces rate of colon cancer. Some observational studies found a reduced risk; however, two recent randomized studies did not find any reduction in colon cancer [N Engl J Med 2000 Apr 20;342(16):1149-55]. A systemic review of five studies involving 4349 patients did not find definitive evidence of reduction either [Cochrane Database Syst Rev 2002;(2):CD003430].

Contrary to a common hypothesis that antioxidant vitamins (vitamins A,C,E) can prevent cancer, randomized controlled trials have shown that these vitamins do not reduce the risk of colon cancer [N Engl Med 1994 Apr 14;330(15):1029-35]. High-dose of vitamin E (>400IU/day) may actually cause harm.

Calcium may protect the epithelium, i.e. inner lining, of colon. Calcium, taken at high dose of 1000mg or more a day, may reduce risk of colon cancer [Cancer Epidemiol Biomarkers Prev. 1998 Feb;7(2):163-8]. It appears that calcium should be taken for a long time to reduce the risk.

In short, calcium of high dose is better than fiber and antioxidant vitamins in reducing the risk of colon cancer.

Sogno by Andrea Bocelli

Aspirin and Colorectal Cancer

Increasing incidence of colorectal cancer with advancing age

"Does low-dose aspirin I am taking to prevent heart attack also helps prevent colon cancer?" you may ask.

Well, many clinical trials and meta-analysis studies were conducted to evaluate risks and benefits of aspirin in prevention of colorectal cancer. Several studies concluded that aspirin was associated with a 20-40 percent reduction in the risk of colorectal cancer in people who had average risks. However, this benefit was observed only in patients who consistently took high dose of aspirin for 10 to 14 years. Taking high dose of aspirin is associated with adverse effects such as gastritis, duodenitis, gastroduodenal ulcers, bleeding, hepatitis, renal failure.

There is evidence that low-dose aspirin, 81-162mg, which is used in prevention of coronary heart disease, is not associated with a reduction in the risk of colon cancer.

For people with high risk of cancer such as those with familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer or personal history of colon cancer, more studies are needed to elucidate the net benefits and risks of aspirin use.

At this time, the United States Preventive Services Task Force does not recommend use of aspirin for prevention of colorectal cancer because risks outweigh benefits.

Evening Falls by Enya

When the evening falls, and the daylight is fading

From within me calls; could it be I am sleeping?

For a moment I stray, then it holds me completely

Close to home, I cannot say

Close to home, feeling so far away

As I walk the road, there before me a shadow

From another world, where no other can follow

Carry me to my own, to where I can cross over

Close to home, I cannot say

Close to home, feeling so far away

Forever searching, never right

I am lost in oceans of night

Forever hoping I can find memories

Those memories I left behind

Even though I leave, will I go on believing

That this time is real; am I lost in this feeling?

Like a child passing through, never knowing the reason

I am home; I know the way

I am home, feeling, oh, so far away.

Colon Cancer & Diagnosis

Colon cancer seen by colonoscope

Colo-rectal cancer is a common and lethal disease in North America, Australia, and Europe. 90 percent of the disease occur after age 50. In the U.S., deaths from colon cancer account for about 9 percent of all cancer deaths every year.

Most of colon cancer arise from the mucosa, the inner lining of colon. At present time, colonoscopy is the best diagnostic test by which doctors perform biopsy. Another test, called barium enema (BE), is also used in 5 percent of patients in whom the colonoscope is not able to reach tumors because of obstruction cancer, tortuous colon. It is important that the whole colon be examined, so that other co-existing tumors are not missed.

A blood test, called carcinoembryonic antigen (CEA), is not recommended as a screening test for colon cancer. However, the blood level of CEA has prognostic utility; meaning it can predict if a patient with colon cancer will do well in the future.

CT scan is commonly used in detecting metastases. Its greatest benefit is to help avoid unnecessary surgery in patients who have distant metastases but do not have symptoms such as bleeding, obstruction.

PET scan is most helpful in detecting recurrence of colon cancer in patients who have high CEA level but in whom cancer is not found by CT, BE, colonoscopy.

Ennio Morricone & Once upon a Time in the West

Restless Leg Syndrome

Wall leg stretching: Stand facing a wall, feet together, 0.5 meter from the wall. Hold heels firmly on the wall. Keep hips and knees straight. Lean forward to the wall, stretching both legs. Hold this position for 15-30 seconds. Repeat five times per session. Do three sessions a day.

Muscle cramping of legs, also known as "vop be" in Vietnamese, is a common complaint for various illness. Common causes are prolonged sitting, arthritis, dehydration, low blood potassium or magnesium, iron deficiency, muscle cramping from vigorous excercise, diabetic or alcoholic peripheral neuropathy, Parkinson disease. In many cases, patients notice that cramping is worse in the evening and immediately relieved by walking. These patients may well have restless leg syndrome (RLS).

The International Restless Legs Study Group proposed the following four symptoms as essential criteria for the diagnosis of RLS:

• An urge to move both legs



• The urge to move begins during periods of rest such as lying or sitting



• The urge is relieved by walking or stretching



• The urge is worse in the evening or at night

In some cases, polysomnography, which is a sleep study, is needed for the diagnosis.

As far as treatment is concerned, leg stretching (see picture) before sleep is a good start and not costly at all. Avoidance of caffeine, nicotine, and alcohol helps many patients. Pharmacological treatment is available. Levodopa, pramipexole, ropinirole, benzodiazepines, or gabapentin are usually recommended.

Trinh Cong Son & Khanh Ly

Treatment and prognosis of small-cell lung cancer

Chest CT scan shows a central mass with adenopathy confirmed as small cell carcinoma.



Small cell lung cancer (SCLC) occurs almost exclusively in cigarette smokers. Although SCLC is highly responsive to chemotherapy and radiation therapy, it usually relapses within months depite treatment.

Choice of treatment, prognosis depend on disease staging at the time of diagnosis. Veterans' Affairs Lung Study Group has recommended a simple and clinically useful staging system:

• Limited-stage SCLC is defined as disease confined to ipsilateral hemithorax, meaning to the same side of the chest


• Extensive-stage SCLC is defined as disease extending outside the ipsilateral hemithorax

Without treatment, patients with SCLC survive only a few months. With chemotherapy or radiotherapy, survival is significantly prolonged.

• 80-90 percent of patients with limited-stage disease respond to chemotherapy plus radiation therapy


• 60-80 percent with extensive-stage disease respond to chemotherapy


• chest radiotherapy is usually for those with limited-stage disease


• median duration of responses is 6-8 months


• median survival for limited-stage disease is 14-20 months, extensive-stage disease 8-13 months

Winter by Vivaldi

Glucosamine and Chondroitin

Osteoarthritis (OA) is common in the elderly. It is important to know that osteoarthritis (OA) is different from rheumatoid arthritis (RA) and osteoporosis, since RA and osteoporosis require different treatment.

Available therapeutic options for osteoarthritis (OA) are exercise, weight loss, medications, surgery. Many people nowadays take supplements such as glucosamine and chondroitin, hoping to relieve pain and improve function. However, these supplements are often incompletely effective.

A 2005 meta-analysis study of glucosamine showed a significant improvement for pain relief. However, the largest randomized placebo-controlled study did not show significant differences in pain after 24 weeks of treatment with glucosamine, chondroitin, or the combination of both supplements [N Engl J Med. 2006 Feb 23; 354(8): 795-808]. Further clinical research studies are needed.

Adverse effects of these supplements are minimal. Most common symptoms are abdominal bloating, diarrhea.

Scent of Yesteryears

Prevention of malaria for world travelers

Arrows pinpoint a red blood cell infected by malaria parasite

Some of my friends once had spirited debate as to properly prevent malaria before they departed for overseas travel. It is interesting to know that malaria is transmitted by the bite of female Anopheline mosquitoes (how do we tell apart male and female mosquitoes may require an insect biologist's expertise, I guess) And malaria-transmitting mosquitoes feed at night; therefore, it makes sense to limit exposure between dusk and dawn. Effective preventive measures are:

• Using mosquito nets


• Covering skin with clothing


• Applying insect repellent

Travel to malarious regions, no matter how transient it is, requires the use of chemoprophylaxis, i.e. prophylactic medicines. Choices of medicines vary depending on geographic locations.

Travelers to Africa, South America, Indian subcontinent that consists of India, Pakistan, Bangladesh should take either mefloquine, or atovaquone-proguanil (Malarone), or doxycycline.

Travelers to most parts of China and southeast Asia should know that they may not have to take prophylactic medicines if they visit only urban areas. It is also important to know that resistant strains of Plasmodicum falciparum are prevalent in this part of the world. Therefore, only doxycycline or Malarone are recommended.

If you wish to know more details of malaria as reported by country, I recommend CDC (Center for Disease Control) website: http://www.cdc.gov/.