Archive for the ‘Diabetes’ Category

Spinal Stroke: An atypical cause of back pain

Monday, April 11th, 2011

When one hears the word stroke, what typically comes to mind is a “brain attack” with slurred speech or numbness and weakness of the right or left side of the body. Well, the spinal cord is considered part of the central nervous system and is truly a direct connection to the brain. All of the data received through nerve endings in our bodies passes through the spinal cord to be interpreted in the brain. Likewise, the messages our brain is sending to our bodies, both consciously and unconsciously (e.g. walk, run, write, speak; and digest food, breath, increase heart rate, etc.), travel through the spinal cord to our peripheral nerves.

The spinal cord is a vital structure that has its own blood supply, much like other organs, including the heart and brain. Just like the blood vessels supplying the other organs, the spinal arteries, especially the anterior spinal artery, can become occluded (i.e. blocked) resulting in spinal cord ischemia or infarction. The nerve information can no longer travel to and from the brain or the body freely; it is interrupted. This equates to a “stroke” of the spinal cord with resultant numbness, weakness, paralysis, as well as bowel and bladder dysfunction below the level of the infarction/stroke.

What causes a “spinal stroke”?

The most common cause of spinal stroke is the same as that for brain stroke or heart attack……atherosclerosis, an accumulation of cholesterol plaque in the arterial wall that ultimately blocks the artery. No blood flow means no oxygen or nutrients to the cells and tissues of the spinal cord resulting in them “starving to death.” There are other causes, as well; anything that compresses one of the supply arteries can block blood flow to a region of the cord and result in “stroke.”

Tumors, either primary or metastatic, can compresses blood vessels and other structures as they grow in the spinal region. Anterior disc herniations and disc ruptures or bone fragments from traumatic fractures of the vertebrae can compress blood vessels in the immediate vicinity.

Collections of pus from infectious processes can interrupt the blood supply either by compressing a vessel or disintegrating the blood vessel.  Small pieces of blood clots (called emboli) can break-off from larger clots (called thrombi) and circulate through the bloodstream until they get “stuck” in a smaller vessel somewhere else in the body; the spinal artery is just one location. Other systemic diseases can result in vasculitis, or an inflammation of the blood vessel, that leads to clotting and occlusion of that vessel, and the spinal artery is just one of the vessels that can be affected.

Surgery and spinal stroke

Interestingly, inter-abdominal and spinal surgical procedures can also lead to spinal cord ischemia and stroke. Individuals undergoing repair of an aortic aneurysm or iliac-to-femoral artery bypass often require “cross-clamping” of the aorta above the level of the surgery. The “golden hour” referred to in heart attack victims can also be applied to other vascular ischemic conditions, like spinal artery ischemia; if complications arise and the cross-clamp time is too long, it can result in ischemia from which the patient may never recover, remaining paralyzed for life. Similarly, an aortic dissection can disrupt blood flow to the smaller arteries branching from the aorta to feed the spinal cord leading to ischemia.

Spinal surgeries take one of two approaches, anterior (going through the belly) or posterior (going through the back). Because of the proximity of all of the vital structures, including the major blood vessels, small errors or retained fragments can lead to occlusion or disruption of the spinal blood supply.

Who is at risk for spinal stroke?

Those individuals with risk factors for heart disease or brain stroke are also at risk for spinal stroke since they share a common etiology. This includes those individuals with poorly-controlled diabetes, high cholesterol or dyslipidemia, abnormal clotting of the blood, peripheral arterial disease or history of aneurysms.

What are the symptoms of a spinal stroke?

Most patients present with sudden, severe pain, much like a heart attack, in either the chest or the back or both. This pain is typically rapidly followed by numbness, or loss of pain sensation and temperature sensation, in the extremities below the level of the stroke. Because of the anatomy of the blood supply, vibration sensation and position sense are maintained in the affected region since the posterior region of the cord has a different blood supply. As the spinal stroke progresses over an hour or so, the extremities affected become weaker and weaker, often experiencing paralysis, and the bowel and bladder lose their innervation leading to dysfunction and incontinence. This is a fairly rapid progression, much different that other myelopathies.

What is the treatment?

Due to the relative rarity of this condition, not many studies have been done regarding treatments. Unlike “heart attack” or “brain attack,” there are no standards of care except for aspirin therapy and (potentially) anti-platelet therapy after the stroke has occurred. More often than not, there is a delay in diagnosing the condition due to the rarity of the condition and the need to confirm the diagnosis by a diffusion-weighted enhanced MRI of the spine, such that “clot-busting” agents are time-excluded from use. Treatments are then focused on preventing additional vascular events, preventing deep vein thromboses in the paralyzed limbs, preventing bladder infections and fecal impactions, preventing decubitus ulcers and soft tissue infections, and preventing the additional morbidity associated with paralysis. This is not a comforting thought!

We are blessed with today’s medical technological advances that allow for so many life-saving procedures and procedures that preserve body function, such as spinal surgery, vascular stenting procedures and epidural injections. Unfortunately, some of these procedures have increased the incidence of spinal strokes due to the nature of the procedures themselves. The current epidemic of obesity and metabolic syndrome is also indicative of more cases of diabetes and atherosclerotic vascular disease which, according to the law of probability, will increase the incidence of this potentially devastating medical condition.

Clinical Trials Underway

Do you know someone who has had a spinal stroke? What was his or her age? What might have precipitated the “attack”? Some individuals have been in their early 20′s when the attack occurred. Needless to say, this is truly devastating! With all of our advanced technology, we should be doing a better job of preventing, diagnosing and treating this condition. The National Institutes of Health (NIH) does offer clinical trials for this condition; please refer to their website for further information. ( http://www.ninds.nih.gov/disorders/spinal_infarction/spinal_infarction.htm)

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Decreasing Obesity Risks in Children: Another Benefit of Breastfeeding

Friday, March 25th, 2011

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In the United States today, one of the major health problems is obesity. The CDC reports that “[i]n 2009, only Colorado and the District of Columbia had a prevalence of obesity less than 20%.”  The number of both adults and children who are obese is huge and continues to rise dramatically.  The CDC website provides maps that show just how prevalent this problem is in our country. Particularly troubling is that “[t]hirty-three states had a prevalence equal to or greater than 25%; nine of these states (Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and West Virginia) had a prevalence of obesity equal to or greater than 30%).  This represents an enormous number of people in our country who are at risk for major health complications, such as “cardiovascular disease, certain types of cancer, and type 2 diabetes.”

While there has been an emphasis in our country on various ways to decrease these obesity statistics (including improving nutrition and increasing exercise), I wonder whether additional emphasis should be paid to children being given a great start to health. A recent article in the Baltimore Sun caught my attention. The article explains how diabetic moms, including those who had gestational diabetes during pregnancy but are not otherwise diabetic, are both more likely to give birth to a larger than average baby and also how their child is “more likely to become obese in childhood.”  The good news, the article explains, is that:

…a new study says that if you breastfeed your baby for at least six months, your child will be no more likely to put on weight than those whose moms are not diabetic.

This is just one more example of how breastfeeding for at least six months can dramatically improve your child’s chances of lifelong health.  Through breastfeeding alone, these moms can erase the increased risk that these children will become obese.

What they found appears to be a real advantage for breastfeeding: If the babies had been breastfed for six months or more, children born to diabetic moms looked nearly the same as the children of non-diabetic moms. And they were no more likely to be obese.

On the other hand, children who were breastfed for less than six months — and who had been exposed to diabetes in the womb — had significantly higher BMIs, thicker waists and stored more fat around their midsections than the other children in the study.

While I was excited to read about one more reason to support breastfeeding, I was concerned about whether this is a realistic choice for many families in our country.  Many moms who are committed to breastfeeding their children and who are successful at the start, do not continue breastfeeding for at least six months. The CDC Breastfeeding Report Card for 2010 says that “…3 out of every 4 new mothers in the United States now starts out breastfeeding… However, rates of breastfeeding at 6 and 12 months as well as rates of exclusive breastfeeding at 3 and 6 months remain stagnant and low.”  The national average is that while 75% of moms have breastfed, only 43% are breastfeeding at all at 6 months and only a mere 13.3% are exclusively breastfeeding at 6 months.  At 3 months, a time when infants would not have started solid food, only 33% of moms are still exclusively breastfeeding.  This means that there is a large drop off from what moms do when their babies are born and what they are doing by the time their babies reach 3 months.

However, the study about diabetes found that at least six months of breastfeeding was essential in protecting these kids from the increased risks of obesity. From both personal experience and anecdotal evidence, I suspect that many families are facing hard decisions about employment and breastfeeding. I suspect that a significant part of the large drop off between the numbers of moms’ breastfeeding at birth and those breastfeeding exclusively at 3 months has to do with employment. Given that the US lags so far behind other countries in paid parental leave, most moms have no choice but to go back to work full-time by the time their infants are 3 months (if not earlier).  Many moms face no choice at that point but to stop or severely limit breastfeeding, as few employers offer the time, space or scheduling to truly make moms successful at the difficult job of trying to pump while working.

I believe that the health care costs of treating individuals with obesity and all of the associated health problems should be examined against the costs of providing more complete support to new families.  What do you think?  Could employers better support breastfeeding in an attempt to increase the number of healthy children whose risks of obesity are lowered? Do you think that lack of paid leave or increased support in the workplace for breastfeeding is really the reason for decreased breastfeeding or are there other factors at play?

 

 

Kicking Off Diabetes Awareness Month – Prevention Saves Lives!

Tuesday, November 2nd, 2010

November marks Diabetes Awareness Month. Most people believe diabetes to be a benign disease, one that does not cause high risk complications and is easily managed through proper insulin administration.  However, diabetes is the seventh leading cause of death in the United States and increases one’s risk for high blood pressure, heart disease, stroke, kidney disease, blindness, nervous system damage and amputation.

WHAT IS DIABETES?

Diabetes is a chronic condition that impairs the body’s ability to use food for energy.  The hormone, insulin, made in the pancreas, is a hormone that allows glucose (sugar) to enter cells and be converted to energy. When diabetes is not controlled, glucose and fats remain in the blood and, over time, damage vital organs.  There are several types of diabetes: Type I, Type II, prediabetes and gestational diabetes.

Type I – usually diagnosed in children and young adults. Type I diabetes can be caused by genetics, environment or an autoimmune disorder. It affects 5% of the diabetic population and there is no known way to prevent this type.

Type II – is linked to obesity and physical inactivity. It is also associated with older age, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, race, and ethnicity. This type of the disease affects 90-95% of the diabetic population.

Prediabetes- is a condition in which a person has blood glucose levels higher than normal but not high enough to be classified as diabetes. An estimated 57 million American adults had prediabetes in 2007. People with this condition have an increased risk of developing type 2 diabetes, heart disease, and stroke.

Gestational Diabetes – is a form of glucose intolerance diagnosed during pregnancy. Gestational diabetes occurs more frequently among African Americans, Hispanics/Latinos, and American Indians. It is also more common in obese women and women with a family history of diabetes. Gestational diabetes requires treatment to normalize maternal blood glucose levels to avoid complications in the infant. Women who have had gestational diabetes have a 35%–60% chance of developing diabetes during the 10–20 years following their pregnancy.

THE COSTS OF DIABETES

Diabetes is a costly disease with $1 out of every $10 spent on health care going towards diabetes and its complications. Total costs (direct and indirect) of diabetes are $174 billion annually. Furthermore, people with diagnosed diabetes have medical expenditures that are about 2.3 times higher than medical expenditures for people without diabetes.

WHY DIABETES AWARENESS IS IMPORTANT

If current trends continue, 1 in 3 Americans will develop diabetes sometime in their lifetime, and those with diabetes will lose, on average, 10–15 years of life.The United States saw a 136 percent increase in the number of people with diabetes between 1980 and 2007. Now, nearly 24 million Americans have the disease. However, research has shown that Type II diabetes, which affects the majority of diabetics, is preventable.  Lifestyle changes, including weight loss and an increase in the amount of physical activity per week, can reduce the rate of onset of type 2 diabetes by 58%. Further, disability and premature death are not inevitable consequences of diabetes. People with diabetes can prevent premature death and disability by controlling their blood glucose, blood pressure, and blood lipids and by receiving other preventive care in a timely manner through proper medication administration and lifestyle changes.

Making those lifestyle changes with regard to diet and exercise are not easy. However, the health costs and risks for not making those changes is enormous. So – let’s raise the level of awareness for this disease so we can prevent future cases and help those already afflicted with the disease to better manage their symptoms. As part of our pledge to stop diabetes, Nash & Associates will be posting periodic fitness tips, statistics and maybe an occasional recipe or two for healthy alternatives to some of our favorite not-so-good for you dishes.

If you have a health tip or dietary trick to share in support of Diabetes Awareness Month, please post a comment below! Tell us your story of how this horrible disease has affected you, a family member or a friend or and share with all of us some great stories of how you, a family member or friend beat this dreaded disease.

For more information about diabetes, you can always visit the American Diabetes Association website.