Health Information for Your Health Needs

Severe Mitral Valve Regurgitation Symptoms and Treatment

2015-03-09T04:43:00.002-07:00

Severe mitral valve regurgitation may be divided into two kinds: ischemic or non-ischemic. Ischemic mitral valve regurgitation is due to coronary artery disease and is associated with blocked arteries. It can occur in association with myocardial infarction or heart attack. Non-ischemic mitral valve regurgitation may be due to a myxomatous mitral valve such as what occurs in mitral valve prolapse. It can also occur due to infectious processes such as rheumatic fever or infective endocarditis or due to congenital anomalies.

Symptoms of Severe Mitral Valve Regurgitation

Most patients with severe mitral regurgitation suffer from chronic fatigue, difficulty of breathing or shortness of breath with activity or when lying flat on bed. Some develop palpitations which may be due to an abnormal heart rhythm called atrial fibrillation. Swelling or edema of the ankles and enlargement of the abdomen and the liver may also occur once the right side of the heart becomes involved.

Patients who develop acute severe mitral regurgitation, such as those who suffer from heart attack, may develop pulmonary congestion. This also results to difficulty of breathing.

Treatment of Severe Valve Mitral Regurgitation

Among symptomatic patients with severe mitral regurgitation, findings revealed by the two-dimensional echocardiogram (2D-echo) help the doctor decide the treatment.

Mitral valve repair is the procedure of choice as the risks and the mortality rate of primary repair are lesser than that of replacement. For instance, for isolated mitral valve repair, the mortality rate is 1.8% versus 5% in mitral valve replacement. In addition, there are less long-term undesirable consequences in mitral valve repair.

Sometimes, the findings on 2D Echo are not favorable for either mitral valve repair or replacement. These findings include an ejection fraction of less than 30% and an end-systolic dimension of more than 50 mm. If this happens, medical therapy is preferred.

What is a Strangulated Hernia?

2015-02-14T19:04:00.001-08:00

A hernia simply refers to the protrusion of an organ outside of a cavity or space that normally encloses it due to a weakness in the walls of the cavity. In surgery, there are different types of hernias usually pertaining to the bowels. In most cases, a herniated bowel can be reduced, either spontaneously or with manual compression. Reduction means the return of the herniated organ into its original position.

However, strangulation of hernia can occur. So what is a strangulated hernia? A strangulated hernia is one that cannot be reduced to its original position and becomes trapped through the opening of the cavity. When it becomes trapped, the strangulated bowel eventually loses its blood, oxygen and nutrient supply.

Symptoms of a Strangulated Hernia

The symptoms of a strangulated hernia are the same as the symptoms of bowel strangulation. Bowel obstruction symptoms heralds bowel strangulationsymptoms. A person who has a strangulated hernia often experiences vomiting, constipation, bloatedness and abdominal enlargement or distention due to bowel obstruction. As the bowel strangulation progresses and the strangulated hernia loses its blood and oxygen supply, severe abdominal pain occurs, accompanied by the fever. One distinguishing characteristic of the pain of bowel strangulation is severe abdominal pain not relieved by any position.

When a patient with strangulated hernia presents at the emergency department, the patient is often septic due to the acute abdomen. Emergent surgical management is needed for these kinds of patients.

Diagnosis of a Strangulated Hernia

The diagnosis of a strangulated hernia is based on history and physical examination findings. Patients usually have a long-standing palpable lump on their groin or abdomen. Their past medical history might reveal a previous diagnosis of hernia while their recent history reveals the presence of intestinal obstruction symptoms. Imaging studies such as CT scan may be requested to document bowel strangulation. Blood counts often reveal elevated white blood cell counts with neutrophilic predominance as a sign of sepsis. Blood chemistry usually reveals deranged electrolytes due to fluid shifts and losses.

Treatment of a Strangulated Hernia

The definitive treatment for a strangulated hernia is surgery. The type of surgery depends on the type and location of the hernia. Different approaches may be used. Non-mesh repairs are advisable in cases of bowel resection.

Easy Ways on How to Relieve Constipation

2015-02-11T06:14:00.000-08:00

One of the most irritating symptoms among adults is constipation. It is often a source of discomfort and embarrassment especially among working adults. Not many people are aware of ways of relieving constipation. However, the ways to relieve constipation are actually very easy. By following the following steps on how to relieve constipation, you can have easy and effortless bowel movements daily.

1) Drink plenty of water.

Constipation can occur when there is not enough water in the stools. Because the large intestines reabsorb a lot of water from fecal material, the actual stools can become very hard if there is not enough water in one’s daily oral intake. The advice that one should drink 6-8 glasses of water per day can go a long way in relieving constipation. In times of warm weather where insensible losses such as sweating can further decrease the total body water, increasing water intake is the key to avoiding constipation.

2) Eat a high-fiber diet.

Aside from cleansing the bowels, foods high in fiber can help prevent constipation by keeping fecal material softer. In a sense, a high fiber diet translates to soft stools because the collagen somehow serves as an absorbent, sponge-like material. This lessens the changes of passing hard stools. In addition, eating a high-fiber diet can help prevent straining, which in turn can cause hemorrhoids.

So what are examples of what to eat to relieve constipation? Green leafy vegetables and fruits with lots of collagen and water will do. These include lettuce, broccoli, watermelon, papaya and a lot of other fruits and vegetables.

3) Eat less meat

While fruits and vegetables form the bulk of what to eat to relieve constipation, meat is at the other end of the spectrum. People who love to eat meat are more likely to suffer from constipation and hemorrhoids.

4) Use stool softeners or laxatives

One way of how to relieve severe constipation is using stool softeners or laxatives to promote bowel movement. Unfortunately, like any other drug, these can have side effects. Although most can be bought over-the-counter, it is better to use them under the supervision of a physician so that such side effects can be avoided or monitored.

If these ways to relieve constipation do not work and constipation is associated with other symptoms such as diarrhea, weight loss, or blood inthe stools, do not hesitate in seeking professional healthcare. While constipation is an embarrassing symptom and can often be addressed at home, the presence of other symptoms can herald more complicated diseases. Hence, if trying to relieve constipation on your own does not work, it is but wise to consult a doctor.

Causes of Blood in Stools

2015-01-31T01:54:00.000-08:00

One of the most common causes for consult in the Emergency Room or the Emergency Department is blood in stools. Most often than not, the patient is a middle-aged adult who had either saw gross blood in stools or who had blackish stools, signifying processed blood. Moreover, these patients are likely to be anemia and need blood transfusion.

So what causes bloody stools? The following are the most common diagnoses of bloody stools I have seen in the ER.

1. Hemorrhoids
Hemorrhoids commonly cause bloody stools. Irritation and inflammation of the anorectal mucosa because of straining and constipation from a low fiber diet leads to hemorrhoid formation. Fortunately, most hemorrhoids are not complicated and can be resolved by a diet containing high fiber and plenty of water and proper hemorrhoid care. Avoidance of straining is also a must. Sometimes, doctors may prescribe medications to help decrease the inflammation or to soften the stools.

2. Other Colorectal diseases
Colorectal diseases can also cause blood and mucus in stools. Colorectal diseases include diverticulosis or diverticulitis and colorectal cancer. Diverticulosis can be addressed by dietary changes but diverticulitis is often treated with antibiotics and sometimes, surgery. Colorectal cancer should always be a consideration among adults who have a family history of bowel cancer.

3. Peptic ulcer
Peptic ulcer disease refers to both gastric and duodenal ulcers. These ulcers usually cause abdominal pain as well. Most ulcers, when they bleed, cause blackish foul-smelling stools medically termed as "melena". However, sometimes, when peptic ulcers bleed massively, they can cause grossly bloody stools we call "hematochezia". Bleeding peptic ulcers usually cause varying degrees of anemia. It is prudent to immediately cause a gastroenterologist when you suspect you have a peptic ulcer in order to have an endoscopy done as soon as possible.

4. Liver Disease
Chronic liver disease, whether it is due to alcoholic, viral or malignant causes, can cause bloody and mucus in stool through two main mechanisms: 1) acquired coagulopathy, 2) bleeding esophageal varices. Acquired coagulopathy simply means that the liver is failing to produce enough coagulation or clotting factors. Hence, any mucosal break in the gastrointestinal tract can bleed spontaneously. Esophageal varices are blood vessels that enlarge because of the high pressures causes by a dysfunctional and cirrhotic liver. They are often managed with ligation via endoscopy by a gastroenterologist.

5. Infection
Infection is still the most common cause of bloody mucus in stool among children. Bloody mucus in stools accompanied by severe abdominal pain and fever, often require antibiotics. However, infections are less common causes of blood in stools among adults due to higher rates of observance of hand hygiene. To prevent infection causing bloody stools, it is therefore prudent to always wash hands and eat only well-cooked food and drink clean water.

What Causes a Heart Attack?

2015-01-24T02:12:00.000-08:00

What Causes a Heart Attack?

Just yesterday, I received a patient in the ER who suffered from heart attack. Heart attack, called in medical terms as myocardial infarction, is one of the top diagnoses in the ER and is also a leading cause of death in today’s world. The basic mechanism of a heart attack is the presence of a low blood supply to the heart in the face of great demand. Knowing what causes a heart attack is essential in preventing it.

There are several heart attack causes. One cause of heart attack is the formation of obstruction within the blood vessels of the heart, otherwise known as the coronary vessels. Several risk factors that cause heart attack of this type have been identified. These risk factors include the following: hypertension, diabetes, chronic kidney disease, atherosclerosis, chronic smoking and elevated cholesterol levels.

Another one that causes heart attack is the vasospasm of the coronary arteries. This cause of heart attack leads to constriction of the small blood vessels that supply the heart, leading to severe lack of supply of nutrients of oxygen. Several abused drugs, including nicotine and cocaine have been known to cause this type of heart attack.

Severe anemia can also be one of the causes of heart attack. In severe anemia, the oxygen-carrying capacity of the heart becomes severely limited due to the lack of hemoglobin. Patients who are at most risk of suffering from heart attack due to severe anemia are those who are going to undergo surgery or any other high-stress procedure. This is one of the reasons why a person who is going to undergo an operation have to be adequately evaluated and prepared.

Knowing what causes heart attacks helps in addressing the problem. The risk factors have to avoided prudently in order to lessen the risk of heart attack.

What do High Potassium Levels in Blood Mean?

2015-01-22T04:54:00.003-08:00

Among the most common laboratory test results I encounter in the clinic and in the ER are high potassium levels in blood. Potassium (K+) is a very essential substance which helps the cell maintain life. For instance, it helps in the generation of ATP (the energy currency of the cell) through the so called Na+-K+ ATPase. Normally, the potassium level in the blood is lower than the potassium level inside the cell. Hence, when there is low or high potassium levels in blood, we expect abnormalities in the function of the human body as well.

In my experience, the most common cause of high potassium in blood test is still kidney disease. Chronic kidney disease, sometimes called chronic renal failure, decreases the ability of the kidney to excrete potassium into the urine. Hence, potassium levels high in blood becomes the "norm". Unfortunately, when the high blood potassium scenario occurs, different organs are affected. For instance, the heart muscle becomes highly irritable. Therefore, a patient with high blood potassium is prone to undesirable cardiac rhythms or arrhythmias. High potassium levels in blood are known to cause cardiac arrest and death through this mechanism.

When potassium levels high in blood are detected, we can give several interventions. First of all, we can give a drug called calcium gluconate to protect the heart and make it less irritable. This is decrease the risk of arrhyhtmias. Second, we can give GI or glucose-insulin solution to promote the transport of potassium from the blood into the cells. Third, we can give a diuretic called Furosemide to promote excretion of potassium out of the body through the urine. When the potassium level in blood is only slightly elevated, potassium binders such as Sodium Polysterene (Kayexate) may be given. However, these interventions are only temporary measures and may not always work.

For people who already have End Stage Renal Disease (ESRD, also known as Chronic Kidney Disease Stage V), hemodialysis is usually done to promote potassium removal. The other more costly but also more effective option is renal transplant.

High potassium in blood tests should not be ignored because it may be the sole marker of kidney disease. If you have high blood potassium and you also have symptoms of renal disease such as edema, you should get yourself checked by a doctor.

Aloe Vera for Hemorrhoids

2015-01-19T04:41:00.003-08:00

A common question which patients pose when they consult due to hemorrhoids is this: "Is aloe vera for hemorrhoids effective?" It really depends on what kind of hemorrhoid and how severe the hemorrhoid is. When the hemorrhoid is strangulated or thrombosed, home treatment is often necessary. However, if the hemorrhoid is of milder severity, home treatment of hemorrhoid with aloe may be enough.

Let me first discuss what aloe is. Aloe, short for aloe vera, is a well-known herbal medicine. In ancient Egypt, it was praised as the plant of immortality. The main advantages of aloe vera in alternative medicine lies in its soothing and moisturizing properties.

Since pain is a common complaint associated with hemorrhoids, aloe vera for hemorrhoid treatment may be effective. Treatment with aloe vera gel for hemorrhoid pain may be done using aloe gel preparations available in the market. Some people suggest cutting aloe vera leaves, freezing them and applying the strip to the hemorrhoid. However, I am of opinion that commercial preparations are better used as aloe hemorrhoid treatment for the following reasons.

First, commercial preparations are sterile. Hence, they do not bring with them the risk of secondary infection. Second, they usually have more concentrated active ingredients. Since concentration of bioactive ingredients correlates with effectiveness, these are preferable.

If you plan to use aloe for hemorrhoid home treatment, just make sure that what you use is very clean. Make sure to observe appropriate hand hygiene as well. Home remedies are often effective if they are applied properly.

What are the Symptoms of High Blood Pressure?

2015-01-18T13:26:00.001-08:00

As I attend to patients in the ER, I realize that most people are not aware of the symptoms of high blood pressure. Many people take high blood pressure or hypertension for granted due to the supposed lack of symptoms of high blood. Unfortunately, it is this lack of awareness that leads to surprise heart attacks and strokes. In this article, I will discuss the most common high blood pressure symptoms I have encountered.

· Headache

The symptoms high blood pressure cause can be as common as a simple headache. The headache caused by high blood pressure may be similar to tension headache or migraine. For people who have hypertension and experience headache, it is important to check the blood pressure at the time of headache. Blood pressures of equal to or more than 160/100 mmHg can cause headache. Urgent BP control is needed in these instances since uncontrolled blood pressure may lead to stroke (or cerebrovascular accidents).

· Blurring of vision

Blurring of vision is also one of the symptoms of high blood pressure. High blood pressure can cause the small and fragile arteries of the eye to burst leading to blurring of vision. The blurring of vision may be acute or chronic. Documentation of the disease of the eye called hypertensive retinopathy can be done by ophthalmologists. Blood pressure control is still the most important preventive measure for this symptom of high blood pressure.

· Nape pain

Nape pain or nape discomfort can also be one of the high blood pressure symptoms. Like headache, this is one of the high blood symptoms which are nonspecific. It tends to be taken for something else such as musculoskeletal spasm or strain. However, one clue that it is not musculoskeletal in nature is the fact that nape pain due to high blood is not preceded by any strenuous activity or exercise.

· Chest pain

This is one of the more specific symptoms of high blood pressure and is also one of the most dangerous. Chest pain heralds angina, which is precipitated by exertion and relieved by rest. Chest pain may also be due to heart attack or myocardial infarction. Uncontrolled blood pressures accompanied by atherosclerosis or ischemic heart disease greatly increases the risk of heart attack. This is also the reason why blood pressure control is essential among patients who have had a heart attack. High blood pressure means more work for the heart and when there is a mismatch between the demand of the body and of the heart muscle (myocardium), heart attack ensues.

· Difficulty of breathing

Dysfunction of the pumping capacity of the heart can occur due to greatly elevated blood pressures. Difficulty of breathing from high blood pressure can occur when the blood that should be pumped by the heart backflows into the lungs. When there is difficulty of breathing and/orchest pain occurring as high blood symptoms, immediate control of blood pressure should be done by using intravenous medications such as Nicardipine.

· Focal weakness or loss of consciousness

Focal weakness or loss of consciousness due to high blood can occur. High blood pressure can cause rupture of arteries of the brain leading to stroke, which can manifest as weakness or decrease in sensorium. When a stroke occurs due to high blood pressure, rapid lowering of blood pressure is not advised because blood flow to the affected area of the brain has to be maintained. Neurologists are best equipped to manage strokes due to high blood pressure.

People with high blood pressure should not take their illness for granted because it has chronic debilitating consequences. If you have any of the aforementioned high blood pressure symptoms, do not hesitate to go to your doctor. Start blood pressure control early in order to ensure your well-being.

Treatment of Gastritis

2015-01-17T20:29:00.000-08:00

Many adults come to my clinic complaining of gastritis. Gastritis most commonly manifests as abdominal pain, particularly in the epigastric area or the left upper quadrant of the abdomen. There are many causes of gastritis and these include food, drugs, and bacteria. Hence, the treatment of gastritis also involves the treating the causes of gastritis.

Gastritis treatment depends on the cause. Among the most common culprits are foods that increase the acidity of the stomach and relax the lower esophageal sphincter, thereby allowing the reflux of stomach contents and acids into the esophagus. These foods include the following:

Coffee
Soda
Tea
Milk
Spices/Chili

If you think that any of these is causing your gastritis, you have to ensure that gastritis treatment and diet go hand in hand. To prevent your symptoms, you have to observe the gastritis treatment and diet. Treatment can involve oral or IV medications while diet involves avoidance of the said dietary culprits. Some people might not be able to avoid everything at once but gradually eliminating these from the diet is feasible.

Gastritis treatment drugs involve two major groups of medications. One group includes the major stomach acid-lowering drugs. These can be divided into the following:

proton-pump inhibitors such as omeprazole, esomeprazole, pantoprazole and lansoprazole
H2-blockers - such as ranitidine, famotidine
antacids - such as Maalox

While proton pump inhibitors such as omeprazole are mong the most expensive gastritis treatment drugs, they are also the most effective. Usually, if there is no complicating infection, these drugs are given once a day for two weeks to decrease acid production while allowing the lining or the mucosa of the stomach to heal.

Gastritis treatment antibiotics may be prescribed by a physician if there is suspicion or documentation of Helicobacter pylori infection. Helicobacter pylori or H. pylori is a bacterium that promotes ulcer formation in both the stomach and the duodenum. Complete eradication of this microorganism is necessary for ulcers to heal. Different gastritis antibiotic treatment combinations may be used. Gastritis treatment antibiotics include the following: Clarithromycin, Amoxicillin, and Metronidazole. The doctor decides which combination and which doses to prescribe.

So can you treat gastritis at home? Definitely. A trial of proton-pump inhibitors (PPI) and gastritis diet can be done for 2 weeks to see if there is resolution of symptoms. Patients who treat gastritis at home often succeed. However, when the symptom of abdominal pain is persistent and is accompanied by weight loss, dark-colored or bloody stools, and nausea or vomiting, it is important to go to a doctor for a formal consult. An endoscopy may be needed for more accurate diagnosis. If you have the aforementioned warning signs, do not hesitate to seek consult with your physician to find out what is the appropriate gastritis treatment for you.

Difficulty of Breathing and Chest Pain

2015-01-14T19:08:00.000-08:00

Many patients go to the Emergency Room or Emergency Department (ER/ ED) with a chief complaint of difficulty breathing and chest pain. Among adults who have a history of hypertension or elevated blood pressure and diabetes mellitus (DM), the most common culprit for difficulty of breathing is not the lungs but the heart.

So how does one get difficulty of breathing and chest pain? Although the scientific terms and explanations or pathophysiology of the heart disease and difficulty of breathing is quite complex, it can be simplified as follows.

The heart is a muscular organ which is responsible for pushing blood to supply the various organs of the body. It pushes blood against the resistance of blood vessels, which is basically represented by blood pressure. Higher blood pressures, which can be due to clogged arteries from atherosclerosis or from elevated hormones (aldosterone, renin, angiotensin) leads to more strenuous work for the heart. To compensate, the heart hypertrophies. An analogy is a body builder who gets more muscular due to the hard work his muscles push against.

Unfortunately, although the compensation is initially beneficial, it soon becomes detrimental. The heart's capacity to pump blood is also dependent on its ability to expand and fill with blood. When the heart hypetrophies, this ability becomes compromised and the cardiac output or the amount of blood it is able to supply to various organs decreases. Eventually, the heart cannot keep up with the body's demand and this leads to what we call "heart failure" and sometimes, "heart attack".

So how does heart failure and heart attack lead to difficulty of breathing? The lungs are connected to the heart via the pulmonary arteries and veins. The blood that goes into the heart is first oxygenated by the lungs. In a normal heart, the flow of this oxygenated blood is very efficient. Unfortunately, when the heart fails, this flow slows down and the blood from the lungs is stuck there. The lungs therefore become congested. The lungs, instead of containing air, become "wet" with blood. This is why heart failure is also called "congestive heart failure". In heart attack, the difficulty of breathing with chest pain can develop rapidly because the injured heart cannot keep up with the demand. The lungs basically "drown" in blood, hence, people who have heart failure also feel like they are drowning. This explains the association between difficulty breathing and chest pain.

It is important to understand why heart disease can cause difficulty of breathing because many people who have heart disease ignore it until they develop the said symptom. As in any other illness, prevention is better than cure. When you become diagnosed with heart disease, be compliant with your medications. This is to ensure that your risk of developing difficulty of breathing is minimized and you maintain your functional capacity.

Why medicine is not for everyone - Part I

2014-07-28T05:49:00.002-07:00

Over the course of my years in Medicine, I have realized, slowly and painstakingly, that Medicine is not for everyone. The world of blood, gore, death is not for the weak of heart. There is suffering and pain everywhere. Given the number of patients we see who become debilitated for life (of course, we are thankful that they are still alive) and those who leave the hospital in burial shrouds, it is no wonder that a select few only gets to survive as doctors.

I have listed down several things which make Medicine not for everyone.
1) Getting into medical school is as difficult as can be.
Most medical schools require their applicants to be academically inclined, or to at least have high grades. Most applicants are gutted out because of this. However, there are a few of us who actually impress our interviewers and eventually get in. Confidence gives a lot of power.

2) Surviving medical school is even more difficult than getting in.
If getting into medical school is similar to going through the fire, actually being in medical school is like being roasted alive until even your soul turns into ash. You become the most parched social being on earth, simply because you neither have the time or energy to go out. Parties are limited to those organize by the school or your med friends. You do not get to sleep in because there will always be some requirement you have to finish.

3) Graduating from medical school requires you to make difficult choices for the future
Should you become a primary physician? Should you specialize? Or should you just leave the medical profession altogether. Getting that coveted M.D. after your name does not make your life any easier. Instead, it makes it even harder. Now, you are duty-bound to save lives. When someone in a plane asks "Is there a doctor here?", you cannot not respond. At least, back in medical school, you could always make the excuse that you are still a medical student.

- To be continued

Bowel Strangulation Symptoms

2013-04-04T06:50:00.000-07:00

A variety of conditions can cause abdominal pain but one of the rarer and more dangerous ones is bowel strangulation. In medicine, strangulation simply means that a certain anatomic part has lost its blood supply and has the tissues are dead. Hence, bowel strangulation can be defined as the loss of blood supply of a certain segment of the bowel, leading to ischemia and necrosis or gangrene.

What are Bowel Strangulation Symptoms?

Prior to the actual strangulation of the bowel, obstructive symptoms are often present. These symptoms include nausea, vomiting, and constipation. As the strangulated bowel loses its blood supply, severe abdominal pain sets in. Severe abdominal pain unrelieved by any position is one of the characteristic symptoms of bowel strangulation. The release of inflammatory mediators leads to the development of fever.

Signs that give the doctors a clue on bowel strangulation include a very ill-looking patient, in distress because of abdominal pain. Abdominal examination generally shows abdominal tenderness, guarding, and muscle rigidity. The patient's vital signs often progressively worsen as the disease process progresses.

What are the Causes of Bowel Strangulation?

Bowel strangulation can be caused by different conditions. These include small bowel obstruction, hernias,volvulus, intussusception, tumors, and inflammatory bowel disease. Post-operative adhesions may also cause strangulated bowel. However, the end pathology and the treatment are the same: the strangulated bowel has to be surgically removed and the viable bowel saved. Broad-spectrum antibiotics and adequate fluid resuscitation are also given.

Why Women Need Mammograms

2013-04-01T10:39:00.003-07:00

Just recently, I came Just recently, I came across an article entitled 4 Medical Tests Your Doctor Might Be Overprescribing. According to the said article, a mammogram is one of the said overprescribed medical tests. Indeed, there is controversy regarding when women should start getting mammograms done. For instance, the United States Preventive Services Task Force recommend women of ages 50 and above to get mammograms while the American Cancer Society recommend the test for women of ages 40 and above. In a study in 2012 by Bleyer and Welch entitled “Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence” and published in the New England Journal of Medicine, the authors concluded that “breast cancer was overdiagnosed (i.e., tumors were detected on screening that would never have led to clinical symptoms) in 1.3 million U.S. women in the past 30 years” and mammogram only contributed marginally to the detection of illness-causing breast cancer.

The Rationale Behind Mammograms

I beg to disagree though that mammograms are overprescribed. Mammograms are prescribed for a reason and it is to screen for breast cancer. First of all, a mammogram is a screening test. The value of a screening test lies in the fact that it can detect a diseases even among asymptomatic patients. This means that a woman’s early stage breast cancer may be detected, even if she had not yet noted a lump on her breast, breast discharge, breast skin changes, or breast pain. The beauty of screening lies in the fact that the disease can be treated at its early stages.

Dangerous Assumptions on Mammograms

The authors of the study made several assumptions about the overdiagnosis of breast cancer because of mammograms. According to them, for screening to work, there should be one less patient diagnosed with late-stage breast cancer for every additional patient whose cancer was found at an earlier stage. This is an unrealistic expectation of any screening test. It does not mean that a woman who had breast cancer diagnosed with an early stage will not have any recurrences. Some women diagnosed early eventually present with late-stage disease because they tried alternative treatments which did not work.

I personally think mammogram still has value for screening particularly in high-risk women (e.g. with family history of breast cancer). However, physicians should also used logic when requesting for mammograms. Clinical judgment that aims to balance the benefits and the risks should always be utilized by physicians. On the part of patients, any negative thought or feeling or doubt towards a test requested by the physician should be aired out. After all, the patient-physician relationship is based on mutual trust. Without this trust, even the internet can serve as anybody's doctor and the physician becomes just another person who verbalizes the contents of medical books.

Ethics in Medicine: HIV/AIDS and Disclosure

2012-11-14T01:54:00.003-08:00

Ethics in Theory versus Ethics in Practice

Ethics is always challenging but it is particularly intense and, at times, heartbreaking in medicine. During medical school, when our ethics professor presented cases for the discussion (e.g. whether or not a patient should undergo an experimental treatment without assurance of life, therapeutic abortion, euthanasia and assisted suicide), our class always had heated conversations. Understandably, even if most of us were applying the same ethical principles, we each had different approaches to the issues in medical ethics due to differences in context. At least we were able to speak out and have lively discussions.

Although the cases are similar in actual medical practice, the reactions and responses are quite distinct. In discussions of concrete cases by the medical team, there are long periods of silences, when each member tries to gather his/her thoughts and come up with an acceptable response in the background of unease of holding the key to life or death. Oftentimes, each of us ends the ethics discussion with a disturbed face, a lined face and a heavy heart.

Medical Ethics: HIV/AIDS and disclosure

Among the ethical situations in medical practice I have encountered, one of the things that come to mind is the issue of HIV/AIDS and disclosure. One of the core principles in medical ethics is the Principle of Autonomy. Under this principle, a patient has the right to decide for himself/herself, including whether or not to disclose his/her condition.

Our hospital had a patient who is a lawyer, has a girlfriend and has HIV/AIDS. He was dying from PCP (Pneumocystis carinii pneumonia) but he refused to disclose it to his family because of shame. He belonged to a family of lawyers.

Prior to getting intubated, he wrote a letter informing the medical team that any means to hide his diagnosis should be done; otherwise, he would sue the medical team. The medical team agreed to keep his diagnosis a secret. Each time his lawyer brothers and parents asked about his diagnosis, the standard answer was severe pneumonia. It came to a point when the patient’s family threatened the medical team for malpractice, saying “What kind of doctors are you? Are you that incompetent that you can’t even treat a simple pneumonia?”

The patient’s stay in the hospital was relatively brief. Even to his last moment, the medical team kept silent about his AIDS. The medical team continued to face the threat of a lawsuit.

Fortunately, prior to his death, the patient agreed to reveal his diagnosis once he dies. In the end, when the medical team talked to the family, the family stated that they had an inkling of his condition; they just wanted the doctors to admit to it.

What about the patient’s girlfriend then? Although some states require the patient’s partner to become informed regarding the patient’s HIV/AIDS condition, other states don’t. In this case, the law fully extends the right to disclose to the patient. Should the medical team also inform the patient’s girlfriend, who is at risk of the disease?

Further questions to think about in this case are as follows:

If the girlfriend was of no relation to the physicians, it is not the duty of the physicians to inform the patient. What happens if the girlfriend consulted one of the members of the medical team for pneumonia? Should the girlfriend be informed that she is at risk for HIV/AIDS and should be tested?

At this point, a review of the patient-physician relationship is merited. The physician who treated the patient with HIV/AIDS now treats the girlfriend. When a former patient dies, does the principle of autonomy no longer hold true? On the other hand, is it not the duty of a physician to keep the current patient’s well-being at the fore?

What is a Strangulated Hemorrhoid

2012-10-06T23:17:00.000-07:00

Yesterday, a patient came to the clinic complaining of a painful mass in his anal area. On further probing, he also notes fresh blood on his feces. The painful mass has been recurring for 6 months but he previously hesitated to consult because of embarrassment. Several days prior, the painful mass did not regress spontaneously.

Initially, the patient did not want to undergo a digital rectal examination. I was able to convince him after several minutes of explanation. On examination, the painful mass was revealed to be an internal hemorrhoid (originating above the dentate line) that cannot be reduced manually. Therefore, the diagnosis was fourth-degree internal hemorrhoid. Unfortunately, this can become a strangulated hemorrhoid.

What is an internal hemorrhoid?

An internal hemorrhoid is located above the dentate line. Most of the time, patients do not complain of pain but when an internal hemorrhoid develops thrombosis or necrosis, it can cause severe pain.

The grading of an internal hemorrhoid is as follows:

First-degree internal hemorrhoid - bulges into the anal canal. Patients may notice a mass on their anal canal on straining. Hence, it usually becomes apparent when accompanied by constipation.
Second-degree internal hemorrhoid - prolapses through the anus. Patients can feel it on their anal area. However, a second-degree internal hemorrhoid reduces or goes back spontaneously.
Third-degree internal hemorrhoid - prolapses through the anus and does not reduce spontaneously. Therefore, patients often relate stories wherein they push back or manually reduce the hemorrhoid into the anal canal.
Fourth-degree hemorrhoid - at the highest risk of becoming strangulated. It cannot be pushed back or manually reduced. Strangulated hemorrhoids present with severe pain.

Note that this grading system only applies to internal hemorrhoids and not to external hemorrhoids.

How does a strangulated hemorrhoid occur?

The strangulation of any organ occurs when its blood supply is cut off. When the blood supply of an internal hemorrhoid becomes compromised, it is prone to necrosis or death; hence the term strangulated hemorrhoid.

Is it not good then that a strangulated hemorrhoid dies? It is not that straightforward. Complications including infection, gangrene, sepsis, and thrombosis can occur. When a localized infection occurs, an abscess can form. This leads to pus formation and discharge from the area of the strangulated hemorrhoid. Generalized infection or sepsis can also result.

While conservative and medical therapy may be used for first-degree and second-degree hemorrhoids (e.g.dietary fiber, increased fluid intake, and avoidance of straining, stool softeners, over-the-counter hemorrhoid dessicants), it is best to treat third-degree, fourth-degree and strangulated hemorrhoids surgically. The procedure is called hemorrhoidectomy. Different types of hemorrhoidectomy (rubber band ligation, Closed Submucosal Hemorrhoidectomy, Open Hemorrhoidectomy, and Procedure for Prolapse and Hemorrhoids or PPH) can be done depending on the preference of the patient and the expertise of the surgeon.

Heart Disease in Hyperthyroidism

2012-10-05T04:17:00.005-07:00

The previous week, I saw a gaunt-looking patient with bulging eyeballs. His chief complaint was cough of 2 weeks duration, with associated shortness of breath. Just with the chief complaint and the emaciated appearance of the patient, the immediate working impression would have been an infectious condition such as Tuberculosis. The differential is hyperthyroidism, possibly with heart failure.

Further history revealed that the patient has been having difficulty of breathing with exertion, night-time awakening due to coughing, and the use of 2 pillows to prevent a "drowning" sensation.

Imagine my panic when I examined him and found out he had strong tremors and an irregularly irregular heartbeat. Although his thyroid gland was not enlarged, I advised him about a possible thyrotoxic heart disease and requested for an ECG. When he came back, his ECG showed Atrial Fibrillation, more popularly known as "A-fib" among medical personnel. Right then, I knew he had thyrotoxic heart disease.

What is Thyrotoxic Heart Disease?

Thyrotoxic heart disease is so called because it occurs due to the presence of excessive thyroid hormones (T3 and T4) or in hypethyroidism. Hence, thyrotoxic heart disease is sometimes used synonymously with hyperthyroid heart disease. Thyrotoxic heart disease occurs because the cardiac cells are very sensitive to changes in the levels of thyroid hormone in the body.

Both thyroid hormones (T3 and T4) are lipophilic or fat-loving molecules. Therefore, they can enter not just the cell but also the nucleus. In particular, T3 enters the nucleus and binds to Thyroid Hormone Receptors (THRs), which in turn activate a series of nuclear activities. The result is the transcription of several cardiac genes which, in turn, improve the contracting power (myocardial contractility) of the heart muscles. This also leads to increased cardiac output.

Unfortunately, in thyrotoxic heart disease, the increase in myocardial contractility and cardiac output do not correlate to the improvement of cardiac health. Instead, thyrotoxic heart disease ensues.

What are the symptoms of thyrotoxic heart disease?

The most common cardiac manifestation of hyperthyroidism is palpitations. The examining doctor would also note elevated heartbeat (tachycardia), bounding pulses, a dynamic precordium, loud heart sounds, and a systolic ejection murmur.

The most common manifestation of true thyrotoxic heart disease is an irregularly irregular heartbeat typical of Atrial Fibrillation. Instead of the typical lub-dub rhythm of the heart, an A-fib can be heard with a stethoscope as a "lub-lub-dub-lub-du-dub-lub" sound. Although rare in patients who are less than 40 years old, Atrial Fibrillation occurs in 24% to 40% of hyperthyroid patients who are over 50.

Unfortunately, severe or prolonged thyrotoxic heart disease can lead to heart failure. Thyrotoxic heart disease with heart failure would manifest as cough that does not resolve with antitussives or antibiotics, progressive difficulty in doing exertional activities (e.g. walking upstairs), swelling of the legs (edema), and night-time coughing due to a subjective feeling of drowning. In this case, both the thyrotoxic heart disease and the heart failure should be managed aggressively.

What is the treatment of thyrotoxic heart disease?

Thyrotoxic heart disease manifesting as atrial fibrillation WITHOUT heart failure can be treated using a beta-blocker. Among the various beta-blockers, Propanolol is deemed the most suitable because it is known to decrease the peripheral conversion of T4 to T3 (hence reducing the amount of thyroid hormone that goes into the cardiac muscle nucleus). At the same time, since the underlying cause of the thyrotoxic heart disease is the undesirable elevation of the thyroid hormones, anti-thyroid hormone medications such as propylthiouracil (PTU) can be given.

If congestive heart failure is present, the most important goal is to decrease the volume load of the patient. Therefore, diuretics are used (e.g. furosemide). In patients with congestive heart failure AND atrial fibrillation, the anti-arrhythmic drug Digoxin should be considered.

Weight Gain and Being a Doctor

2012-10-03T06:10:00.000-07:00

Being a doctor entails a lot of sitting. In fact, the process of becoming a doctor means approximately 3 years of listening to lectures, 1 year of following residents and consultants do their rounds, and another year of doing simple medical procedures independently during internship. Unfortunately, these activities also make us prone to eating, foregoing exercise, and becoming overweight/obese.

Physician Weight Gain: The Eating Habit

One of the things that gave me real pleasure during my medical school training was eating. Eating served as a reward. Eating served as a way to reconnect with friends and loved ones. In fact, when I get contacted by a non-medical friend, the invitation is often to "Wanna eat dinner at [some tempting place]? It is therefore no wonder that many doctors, even before they get their licenses, already become overweight. Some have it worse; they become obese.

Physicians Dealing with Weight Gain Issues

Unfortunately, there is this issue of physicians being examples to their patients. Can a patient really rely on the advice of physician regarding weight control and weight loss if that physician himself/herself is obese? Or should we, as physicians, implement stricter standards on ourselves, knowing that our appearance also serves as evidence of our health?

Last year, the American Academy of Family Physicians (AAFP) released a document entitled Strategies for Promoting Healthy Lifestyles in Your Practice. Obviously, the document is targeted towards physicians. According to the document, "Most patients already view their personal physician as a role model, and they perceive physicians who practice healthy personal behaviors as more credible and better able to motivate them to make healthy lifestyle choices." This is a big challenge to physicians all over the world. Just imagine a patient thinking "Why should I follow this doctor if s/he cannot make the change himself/herself?" It is parallel to the way a patient who smokes is less likely to listen to smoke cessation advice when s/he has already seen the physician smoking.

On the other side of the coin, physicians who have weight problems are said to be less likely to provide weight loss advice to their patients. Perhaps, on the part of these physicians, there is some degree of embarrassment and shame, leading to evasion of the issue.

Physicians, like any other person, are also prone to genetic and lifestyle problems. The lifestyle of a doctor does not allow a lot of physical exercise (unless s/he likes walking upstairs and downstairs during rounds) and puts a strain on choices for dietary modification (physicians probably eat more fast food than any other subpopulation during training).

However, I am of personal opinion that physicians should also take care of themselves and their weight, similar to the way they care for other people.I believe physicians become more trustworthy if they give lifestyle modification advice and dietary modification advice for weight loss by citing their own experiences and struggles. It helps strengthen the patient-physician relationship and helps the two sides understand each other. In this issue, the best mantra to follow is "Practice what you preach!". It is effective, builds credibility, and provides inspiration to patients.

Contraindications For Herceptin

2012-10-02T02:59:00.002-07:00

Herceptin (generic name: Trastuzumab) by Roche is an anti-breast cancer drug that specifically targets breast cancer cells that produce the protein called HER2. The type of breast cancers that produce HER2 are typically more aggressive, hence the need for early treatment with Herceptin.

Studies on Herceptin For Breast Cancer

In 2 recent studies that compare the effects of 1) extending the duration of Herceptin use to 2 years (HERA) and 2) decreasing the duration of Herceptin use to 6 months (PHARE), it was found out that either change in duration of Herceptin use does not affect the effects of treatment.

Hence, in both studies, the best duration or the gold standard is still a one-year course of Herceptin for HER2+ breast cancer patients in the early stages of the disease.

Contraindications for Herceptin

Contraindications for Herceptin include hypersensitivity to Trastuzumab and lactation.

The main contraindication for Herceptin is hypersensitivity or allergy to Trastuzumab (the active ingredient) or to any other excipient in the Herceptin preparation. Hence, contraindications for Herceptin include allergy to Trastuzumab, L-histidine hydrochloride, L-histidine, α,α-trehalose dihydrate and polysorbate 20.

A hypersensitivity reaction to Herceptin could manifest as itching or rashes. Severe allergic reactions include difficulty of breathing and hypotension (blood pressure falls below normal). A person suffering from Herceptin allergy merits medical care.

Another contraindication for Herceptin is lactation. A mother who is breastfeeding her child should not be given Trastuzumab. However, this medication could be given 6 months after breastfeeding has ceased.

Although not one of the recognized contraindications for Herceptin, heart failure is considered a dangerous condition for Herceptin treatment. Physicians are advised to use caution when using Herceptin for treating breast cancer patients who have been diagnosed with heart failure and coronary artery disease. This is also the reason why cardiac function is regularly monitored among early breast cancer patients who are using Herceptin.

Night-eating Syndrome

2012-10-02T02:29:00.000-07:00

The relationship of obesity and psychiatric disorders is well-known. For instance, the most common side effect of the medications Clozapine (Clozaril) and Olanzapine (Zyprexa) is weight gain. Patients with psychiatric disorders that used these medications typically gain weight from 3 kilograms to 10 kilograms. However, there is a distinct disorder called Night-eating Syndrome which could lead to obesity.

What is the night-eating syndrome?

The night eating syndrome is a disorder characterized by a person eating excessively even if s/he has already had his/her evening meal. The most common trigger is the presence of a stressful life circumstance (e.g. mounting debt, death of a loved one. Once a person starts to suffer from the night-eating syndrome, night-eating recurs daily until the trigger has been alleviated or overcome.

In the drug-induced type of night-eating syndrome, the night eating occurs due to the use of sedatives. The side effect of the sedatives include sleep-walking and eating, thereby making a sedative user more prone to become a night-eater. An example of a drug that induces night-eating is Zolpidem (Ambien).

What is the difference between binge-eating syndrome and night-eating syndrome?

Binge-eating syndrome (bulimia) is characterized by a sudden compulsion to eat huge quantities of food in a short period. Afterwards, a bulimic person condemns himself/herself for the behavior. Binge eating is not episodic whereas night eating is.

Pathophysiology of Myasthenia

2012-10-01T03:01:00.001-07:00

The pathophysiology of myasthenia gravis can be understood by reviewing the physiology of neurotransmission. Myasthenia gravis basically results from a disorder in the neuro muscular transmission between a neuron and a muscle cell.

Normal Neuro muscular transmission without Myasthenia Gravis

The synapse is the space between the axon of a motor neuron and a skeletal muscle cell. This synapse is more commonly called a "neuromuscular junction" or NMJ. In order to bridge the motor neuron and the skeletal muscle, chemical transmission occurs through the release and uptake of neurotransmitters.This is called neuro muscular transmission or simply neurotransmission. In the neuromuscular junction, the neurotransmitter is called Acetylcholine or ACh. An abnormality in this neuro muscular transmission is the basis for the pathophysiology of myasthenia gravis

When an action potential occurs in the nerve, which is the presynaptic (before the synapse) cell, calcium channels open and calcium ions (Ca2+) rush into the axon of the motor neuron. This inward movement of calcium triggers the release or exocytosis of Acetylcholine (ACh) from the presynaptic terminal into the synapse. ACh molecules then travel to the postsynaptic (after the synapse) cell, which, in this case, is a skeletal muscle cell.

On the postsynaptic cell, ACh binds to the Acetylcholine receptor (AChR) which is also a sodium (Na+) and potassium (K+) channel. This is called a ligand-gated channel. With the influx of sodium into the skeletal muscle cell through this ligand-gated channel, the skeletal muscle cell becomes depolarized. With depolarization, an action potential results, which in turn, leads to skeletal muscle contraction.

Therefore, in the normal neuro muscular transmission, the roles of ACh and AChR are essential. In the pathophysiology of myasthenia gravis, the roles of these two become dysfunctional and the normal neuro muscular transmission is disrupted.

What happens in the pathophysiology of Myasthenia Gravis?

In the pathophysiology of myasthenia gravis, the antibodies that the body produces to fight against foreign substances (e.g. viruses, bacteria) become directed to the body's own Acetylcholine receptor (AChR). These antibodies are then called "autoantibodies" This leads to the loss of AChRs and inefficient neuro muscular transmission. Since the AChRs become blocked by the autoantibodies, ACh cannot bind to its receptor. Therefore, there is a decreased number of action potentials, leading to weakness of skeletal muscles, including the muscles of the eyelids.

Treatment of Myasthenia gravis helps alleviate the pathophysiology of myasthenia gravis. For instance, acetylcholine esterase (AChE) inhibitors help prevent the degradation of acetylcholine, thereby increasing more acetylcholine molecules in the synapse and increasing the possibility of ACh-AChR binding. On the other hand, immunosuppressants like prednisone are used to decrease the activity of the immune system and lower the body's production of autoantibodies directed towards the Acetylcholine receptor.

What is Myasthenia Gravis?

2012-10-01T02:37:00.001-07:00

What are the symptoms of myasthenia gravis?

A 35 year old female patient came in to the clinic complaining of weakness. Previously, she noted having droopy eyelids which worsen in the afternoons. Recently, she experiences weakness that seems to affect her whole body. This woman captures the picture of the disorder called myasthenia gravis.

Myasthenia gravis is a neuromuscular disorder that affects approximately 30 in 100,000 individuals. In patients younger than 40, women are more commonly affected. However, in older patients, both sexes are equally affected.

What is the relationship of a thymoma and myasthenia gravis?

A problem with the thymus appears to be a causative factor. In fact, 65% of patients with myasthenia gravis or MG have thymic hyperplasia or proliferation of the thymic cells. Another 15% have a tumor of the thymus called thymoma. This is the reason why some people with myasthenia gravis are treated with a surgical procedure known as thymectomy. However, other treatments for myasthenia gravis include anti-cholinesterase drugs, steroids (e.g. prednisone), and plasmapheresis.

Understanding Primary Headache

2012-09-29T18:20:00.000-07:00

One of your friends suddenly complained of headache, described as occurring on one side of her head, throbbing. She also says she is seeing flashes of light. Should you bring her to a clinic/emergency room or should you buy her pain medications?

Headache is one of the most common complaints seen by doctors. Although it is not always a worrisome symptom, headache can cause significant disability because it prevents people from working or going to school. This is the reason why appropriate understanding of headache is important.

Primary versus Secondary Headaches

The International Headache Society categorizes headache into either primary or secondary headache. In the case of primary headache, the headache itself is the disorder. An example of this is migraine headache. In the case of secondary headache, the headache is just another manifestation of an underlying disease. For instance, when one has sinusitis, s/he can also have headache. The headache is secondary to or is an effect/consequence of sinusitis.

The Most Common Types of Primary Headache

The most common type of primary headache is called tension-type headache or tension headache (69% of primary headaches). It is characterized by the following symptoms.

Chronic or recurrent

Both sides of the head is involved (bilateral)

Characterized by a tight, band-like sensation

Relieved by simple analgesics including paracetamol and NSAIDs

The second most common primary headache is migraine. It occurs in 16% of patients with primary headache. Characteristics of migraine headache include the following.

Episodic

Unilateral - one side of the head is involved

Throbbing

Accompanied by nausea, vomiting and sensitivity to light (photophobia) or sound

May be triggered by excess stress, hormonal fluctuation (in women), lack of sleep, and alcohol/caffeine intake

Visual disturbances: flashing lights, zigzag lines

Other associated symptoms: lightheadedness, vertigo, diarrhea, seizure, confusion

Less common types of primary headache are idiopathic headache (2%), exertional headache (1%) and cluster headache (0.1%).

Based on the previous example, it seems that your friend has migraine headache. Most people with headache can avoid migraine attacks by avoiding triggers. Ways to avoid triggers include avoiding excess alcohol/caffeine intake, maintaining regular sleep patterns, eating a healthy diet, and undergoing regular exercise.

However, some people may not be able to completely avoid triggers or may need additional medications. Medications used for migraine headaches include NSAIDs and serotonin agonists and dopamine antagonists.

NSAIDs are said to be most effective when taken early in the attack. Combining aspirin (NSAID) and metoclopramide (an anti-nausea and anti-vomiting drug) can be used as a substitute for sumatriptan. In severe migraine attacks, these drugs may be ineffecitve.

Serotonin agonists include ergotamine, dihydroergotamine, sumatriptan, frovatriptan, rizatriptan and eletriptan.

When NSAIDs and serotonin agonists fail, the doctor may prescribe additional drugs called dopamine antagonists. These include chlorpromazine and chlorperazine. These may be given orally or through the intravenous route.

Reference: Harrison's Principles of Internal Medicine

Diseases That Cause Chest Discomfort

2012-09-28T18:10:00.000-07:00

After eating dinner, a middle-aged woman suddenly felt chest discomfort. She immediately rushed to the emergency room because of concerns about heart attack. Are her concerns valid? Are there diseases that cause chest discomfort aside from heart attack?

The answer to both questions is "Yes". Chest discomfort can occur due to both benign disorders to life-threatening conditions such a heart attack. This is the reason why physicians are always conscientious when diagnosing the cause of chest discomfort.

Benign Conditions that Cause Chest Discomfort

The most common causes of acute chest discomfort are shown in the following table.

Gastroesophageal reflux	Typical duration is between 10 minutes and an hour, described as "burning " left chest discomfort, occurring in the region of the stomach (epigastric) and below the sternum (substernal), worsened by lying down after eating, and relieved by antacids
Peptic ulcer	Symptoms similar to gastroesophageal reflux but lasts more than an hour
Gallbladder disease (e.g. gallstones, gallbladder inflammation)	Also prolonged; pain may be characterized as burning or pressure-like, typically located on the left upper quadrant or right upper quadrant of the abdomen, may also be substernal. The pain may be relieved with food or antacids but may also be triggered by a meal.
Musculoskeletal disease (e.g. costochondritis)	Duration of pain is variable and chest discomfort is typically described as aching and worsened by movement. In the case of costochondritis, the pain is worsened by inhaling and the painful area in the chest can be pointed by a single finger and is tender.

About 42% of people who complain of acute chest discomfort are eventually diagnosed with gastrointestinal diseases such as gastroesophageal reflux, peptic ulcer, and gallbladder disease. Sometimes, the diagnosis is not specific and is called Acid Peptic Disease.

Dangerous Conditions that Cause Chest Discomfort

Angina pectoris	Characterized as chest pressure, tightness, heaviness, or squeezing that is retrosternal (behind the sternum, the middlemost bone of the chest wall) and lasts between 2 to 10 minutes that is usually triggered by exertion (e.g. exercise)
Unstable ungina	Characteristics similar to angina but generally more severe and lasts between 10 to 10 minutes. Occurs with low degrees of exertion or even at rest.
Myocardial infarction/ Heart attack	Duration is variable and is more severe than angina. People with a heart attack usually make the Levine's sign, wherein they place a clutched fist over the sternum. People with heart attack also sweat profusely and may have cold sweaty extremities.
Pulmonary embolism	Occurs abruptly, may last from several minutes to hours. Chest discomfort is accompanied by difficulty of breathing (dyspnea), increased heart rate and respiratory rate, and a fall in blood pressure (hypotension)

Ischemic heart diseases (IHD) such as angina, unstable angina and myocardial infarction are the second most common causes of chest discomfort, seen in about 31% of patients.

Because of the various causes of chest discomfort, it is important for a person who is experiencing the symptom to immediately consult a doctor, particularly if there are risk factors for the dangerous conditions mentioned herein. For instance, a person who is overweight, smokes and drinks regularly, and lacks exercise, who suddenly complains of acute chest discomfort, may be experiencing angina or heart attack. Aggressive treatment is needed for these conditions because they may lead to death.

Reference: Harrison's Principles of Internal Medicine

Roles of Calcium in the Body

2012-09-22T07:11:00.000-07:00

Although studies have come out that calcium supplements may cause harm by increasing the risk of heart attack, it does not mean that one should discount calcium benefits altogether. The roles of calcium in the body are varied and are essential to normal functioning. These roles of calcium include regulation of heart muscle contraction, blood coagulation, and transmission of impulses from nerves to skeletal muscles.

Calcium in Bones

Bone has 2 fundamental components: the tough "organic matrix" and the strong "calcium salts". On average, compact bone consists of 30% organic matrix and 70% calcium salts by weight.

Bone salts are composed of calcium and phosphate. The major crystalline bone salt is called hydroxyapatite and has a formula of Ca10(PO4)6(OH)2. While the collagen in bone can resist great tension, the calcium salts can resist a high degree of compression. This is the reason why calcium is always associated with bone strength.

Calcium in the Heart and Blood Vessels

The role of calcium in the heart is basically for cardiac muscle contraction. In a physiologic process called actio potential, calcium ions enter the cardiac muscle cell from the extracellular fluid. In turn, this inward influx of calcium ions trigger the release of more calcium ion from intracellular calcium-storage tubules called sarcoplasmic reticulum. As a result, calcium becomes highly concentrated within the cardiac muscle (myocardial) cell. This activates a series of processes among the cardiac muscle elements that leads to myocardial muscle contraction. The cells of blood vessels (vascular cells) also contract in response to high intracellular amounts of calcium.

This mechanism of action of calcium in the heart and the blood vessels is the reason why drugs for hypertension and arrhythmia called calcium channel blockers or calcium channel antagonists work. Calcium channel blockers exhibit their anti-hypertensive and anti-arrhythmic effects by blocking calcium channels that allow passage of calcium into the cells. Examples of calcium channel blockers are diltiazem, verapamil, and nifedipine.

Calcium Supplements Linked to Heart Attack

2012-09-19T23:03:00.001-07:00

What you consume may kill you. This is the message of many scientific studies nowadays. It seems to apply to calcium supplementation as well.

In a study done among 23, 980 participants in the European Prospective Investigation into Cancer and Nutrition (Kuanrong et al 2012), the participants who used calcium supplements were at higher risk for heart attack. This is a disappointing finding for many physicians and patients who expect calcium supplements to benefit them and decrease the risk of osteoporosis.

Previous researches have shown that there is an inverse association between regular dietary calcium intake and the likelihood of getting chronic diseases such as hypertension, diabetes and obesity. Because of this inverse relationship, many have been led to believe that higher intake of calcium, through the use of calcium supplements, can decrease the chances of heart attack and stroke.

In the said study by (Kuanrong et al 2012), the participants were aged 35-64 years without any known history of previous heart attack, stroke or transient ischemic attack (TIA). These group of participants were followed-up for 11 years.

The duration of the study was sufficiently long for the desired outcomes. Statistical analyses of the result showed that users of calcium supplements had a higher risk of heart attack (Myocardial Infarction, MI). In contrast, dietary calcium intake (whether dairy or non-dairy) did not have a significant effect on cardiovascular risk.

How can calcium supplements cause heart attack?

The researchers propose that the increase risk of heart attack from calcium supplementation may be due to acute or immediate increases in the calcium concentration in the blood (serum calcium) after ingesting the supplement. This is in contrast to the calcium which is found in the diet, which does not immediately increase calcium blood levels.

With acute increases in serum calcium, the researchers theorized that there is a higher chance of the formation of calcium deposits in the blood vessels. This can lead to higher cardiovascular risk.

Should doctors not prescribe calcium supplements?
It depends on the risks and benefits of a specific patient. In medicine, the fundamental principle is "Primum non nocere" or "Do no harm". In the case of calcium supplements, the increased risk of heart attack due to regular calcium supplementation appears to be too great a risk compared to its benefits. More studies are needed to prove this link but currently, the evidence points to avoidance of prescribing calcium supplements among physicians.

Is calcium generally bad?
Calcium is a mineral that serves an essential role in many life processes. In fact, it is not just important for bone health but also for skeletal and cardiac muscle contraction. Hence, it is necessary for life.

Therefore, calcium is good. But calcium supplementation may not be that good. The alternative then is to consume calcium from dietary sources (e.g. dairy, fish, vegetables) instead of taking calcium pills.

Reference:

Kuanrong, L, Kaaks, R, Linseisen, J, Rohrmann, S, 2012, 'Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg)', Heart, vol. 98, pp. 920-925, viewed 20 September 2012.