Risk factors of stroke

Risk factors of stroke Stroke is a neurological emergency. Stroke occurs as an end result of diminished blood supply to brain. It produces significant morbidity and mortality in the society. About 20% of patients die within 1 month of stroke attack. It has both modifiable and non modifiable risk factors. Treatment of modifiable risk factors will help in reducing about 80% stroke in the community.

General risk factors for stroke

Non-Modifiable risk factors

• Age - Age more than 55
• Gender - Male 
• Race (ischemic stroke): blacks > whites > Asians 
• History of stroke or TIA.

15-30% of strokes are preceded by TIA.

35% of pts with TIA will have stroke within 5 years.

10% risk of recurrent stroke within first years of stroke.

(TIA – transient ischemic attack).

• Family history.
• Fibromuscular Dysplasia.
• Patent Foramen Ovale (PFO or hole in the heart).

Modifiable risk factors

Modifiable risk facrors are divided into medical disorders and lifestyle disorders.

Medical Risk Factors 

High Blood Pressure.

Atrial Fibrillation.

High Cholesterol. 

Diabetes.

Atherosclerosis.

Circulation Problems.

Lifestyle risk factors

Smoking.                                                                                                

Alcohol use.

Physical Inactivity.

Obesity. 

High risk factors for ischemic stroke

General population (0.6 %/yr)

Asymptomatic carotid bruit : 1.5 %/yr.

Prior myocardial infarction  : 1.5 %/yr.

Asymptomatic carotid stenosis : 2.0 %/yr.

Nonvalvular atrial fibrillation :  5.0 %/yr.

History of TIA : 6.0 %/yr.

Prior ischemic stroke : 10 %/yr.

Rare risk factors

Thrombocythaemia and  thrombophilia ( increased platelet count ) 

Polycythaemia ( Increased hemoglobin) 

Anticardiolipin and lupus anticoagulant antibodies (i.e. antiphospholipid syndrome). 

Endocarditis ( infection of heat valve) 

Low-dose oestrogen-containing oral contraceptives 

Migraine   

Vasculitis (SLE, polyarteritis nodosa, giant cell arteritis, granulomatous CNS angitis) 

Amyloidosis   

Hyperhomocysteinaemia 

CADASIL (cerebral dominant arteriopathy with subcortical infarcts and leucoencephalopathy)

Reduction of stroke risk following control of risk factors

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Risk factors for depression

Depression is the fourth leading cause of global burden of mental ill health. According to WHO it will be the second most common form of disability by 2020 after ischemic heart disease. Depression is a major cause of suicide. Nearly 1 million people die of suicide, annually. Incidence of major depressive disorder is 1 in 20 people during their entire life time. It is more common in women than men.

Depression affect compliance, immune functioning, quality of life and it will lead to unhealthy behaviours in patients. Due to depression patient experience a variety of somatic illness. Less than one half of depressed patients are identified and adequately treated by primary care physician. It is a common condition and is treatable. Hence identification of this syndrome is important.

Risk factors for depression are

1. Gender-common in females. 
2. Genetic/biological vulnerability. 
3. Stress/environmental/life events especially loss events such as bereavement. 
4. Physical illness especially chronic and painful illness.
5. Drugs.
6. Chronic and excessive alcohol intake.
7. Difficulties in interpersonal relationship.
8. Lack of social support with no confiding relationship. 

Pathways to depression

Broadly depression  can be classified as two major groups.

1. “Major” depression – Pharmacologically treated.
2. “Minor” depression – Treated mainly by psychological approaches.

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What is raynauds phenomenon ?

Raynauds phenomenon is due to episodic digital ischemia (decreased blood supply to digits). On exposure to cold there is color change to digits which change on rewarming. Emotional stress may precipitate Raynaud’s  phenomenon. Color changes are well demarcated and confined to fingers and toes.

Phases of raynauds phenomenon

Phase of  blanching/pallor - On exposure to cold there is spasm of arteries in the digits and cause diminished blood supply to digits, so that the the digit appears white. 

Phase of cyanosis - In this phase there is bluish discolouration of digits. There is dilatation of veins and small capillaries and lead to accumulation of de oxygenated blood in the vessels. In both these phases there is coldness and numbness of digits.

Phase of rubor/redness - It occur on rewarming the digit.This is due to dilatation of blood vessels, spasm resolves, so there is reactive hyperemia. In this phase patient experience pain and throbbing sensation. All the three phases need not be present in a given patient. Some patient experience only pallor and cyanosis where as others have only cyanosis.

Classification 

Primary or idiopathic condition is called Raynaud’s disease. Secondary is associated with underlying disease that is known to produce vasospasm.

Raynauds disease

It is more common in females and is usually seen between the age group 20 to 40. Fingers are more commonly affected than toes. Other areas affected may be ear lobes, tip of nose, penis. This is more common in those who suffer from migraine or variant angina. Those with raynauds disease have milder form of Raynaud’s phenomenon.  

Secondary causes of Raynaud’s phenomenon

a) Collagen vascular diseases:

1. Scleroderma (80-90%)
2. Dermatomyositis, Polymyositis(30%) 
3. Rheumatoid arthritis 
4. Systemic lupus erythematosus(20%)

b) Diseases  producing arterial occlusion: 

1. Atherosclerosis of the extremities-Common in men more than 50 yrs. 
2. Thromboangiitis obliterans (TAO) more common in young males who are smokers
3. Acute arterial occlusion 
4. Thoracic outlet syndrome

c) Pulmonary  artery hypertension

d) Nervous system disorders:

1. Intervertebral disk disease
2. Syringomyelia
3. Spinal cord tumors
4. Stroke 
5. Poliomyelitis
6. Carpal tunnel syndrome

e) Disease of Blood: 

1. Cold agglutinins
2. Cryoglobulinemia
3. Cryofibrinogenemia 
4. Myeloproliferative disorders
5. Waldenström’s macroglobulinemia

f) Trauma: 

1. Vibration injury
2. Hammer hand syndrome
3. Electric shock
4. Cold injury 
5. Typing
6. Piano playing

g) Drugs: 

1. Ergot derivatives
2. Methysergide
3. β-adrenergic receptor
4. Blockers
5. Bleomycin 
6. Vinblastine 
7. Cisplatin

Complication of Raynaud’s phenomenon 

Rarely progress to digital ischemia, gangrene, ulceration and auto amputation of digits.

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Quitting smoking is difficult ,Why ?

Principal content of tobacco is nicotine. It is responsible for its addictive behavior. Tobacco smoking produce physical as well as psychological dependence. Many smoke cigarette as way to cope up with stress and depression. So it is a part of many people’s daily rituals. On quitting smoking people experience withdrawal symptoms that is, unpleasant effects. Addicted smokers control nicotine intake by adjusting the frequency and dose of tobacco intake to obtain the desired psychological effect and avoid withdrawal. Even if they know that smoking is harmful, the addictive behavior prevents them from quitting. Not only addiction is preventing cessation other factors such as peer group pressure, advertisement of cigarette companies also make the attempt of cessation difficult.

Methods for smoking cessation

Smokers who are not motivated

• Record smoking status at regular intervals
• Anti-smoking advice should be given.
• Encourage change in attitude towards smoking to improve motivation

Motivated light smokers (smoke < 10cigarette /day)

• Anti-smoking advice
• Anti-smoking support programme.

Motivated heavy smokers (10–15cigarette /day)

• As above plus nicotine replacement therapy (NRT) (minimum 8 weeks).

Motivated heavy smokers (> 15 cigarette /day)

• As above plus bupropion if NRT and behavioral support are unsuccessful and patient remains motivated. 

Placebo or will-power alone has a ~2% chance of abstinence for ≥ 6 months. This can be increased by the following

• Written self-help materials: 1%
• Opportunistic advice from doctor: 2%
• Face-to-face behavioral support from specialist: 4–7%
• Proactive telephone counseling: 2%
• NRT with limited or intensive behavioral support: 5–12%
• Bupropion with intensive behavioral support: 9%.

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Inter vertebral disc prolapse - Clinical features

Functions of Inter vertebral disc
1)     To separate two vertebral bodies and increases available motion.
2)     To transmit load from one vertebral body to the next.
3)     The disc makes up to 20% to 33% of the length of the vertebral column.
4)     Disc increase in size from cervical ( neck) to lumbar region (lower back).
Anatomy
Disc thickness is 3mm in cervical region (neck region) where weight bearing loads are minimum.
Disc thickness is 9mm in lumbar region (low back)

Risk factors for disc herniation are the following

1)     Job requiring heavy and repetitive weight  lifting.

2)     Use of machine tools.

3)     Operation of motor vehicles.

4)     Cigarette smokers and tobacco consumers.

5)     Overtime heavy work,  poor postural habits.

6)     Degenerative changes make the disc susceptible to trauma.

Any trauma which suddenly increases the pressure will result in rupture of posterior fibres of annulus.

Repeated stresses over time cause

1)     Fatigue breakdown

2)     Traumatic rupture

Clinical features of disc prolapse

Patient is usually an adult between 20 -40 age group. Commonest complaint is low backache. It can be acute or chronic sometime pain radiate to the buttock and leg. The pain is increased by flex-ion (stooping forward) episode, straining, sneezing, coughing and relieved by rest. If there is associated, nerve root compression there will be numbness or weakness in lower limb.

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Insulin use - Practical points

Diabetes mellitus is a progressive, metabolic disorder where there are disturbances in carbohydrate, lipid and protein metabolism. It results from insulin deficiency and / or insulin resistance. As the global burden of diabetes is increasing number of patients on insulin also increases. All those who are on insulin must know the following practical points.

Storage of insulin

1. Stored in a cool and dark place, otherwise their potency is lost (Temperature dependent).
2. Do not keep in a freezer compartment. 
3. The vial in current use can be easily kept at room temperature in a dark place without losing any potency. 
4. Cold insulin if injected is painful.

Insulin injection sites

• Absorption of insulin shows regional difference
  Absorption of insulin is maximum from abdominal region followed by upper outer arms, buttocks and upper outer thighs.
• Abdominal region > upper outer arm and buttocks > upper outer thighs
• The site of injection should be rotated within the same area.
• Depth of injection – subcutaneous with insulin syringe.
• Intravenous injection (direct injection into vein), Intravenous infusion , or Intramuscular routes (direct injection into muscle ) are used only during, emergency such as  ketoacidosis or stressful conditions.
• Same site is used for at least one month and rotation is done within the same site rather than rotating to different sites.
• Using same site decreases variability in day to day absorption. 
• Rotation within the same area prevents lipodystrophy.
• Avoid a site with open wounds or blisters.

Injection technique

• If site is clean, there is no need to clean the site with alcohol or spirit. 
• In thin or averagely built person, lift or grasp a fold of skin between thumb and index finger and inject at 45° or 90°.
• In obese person, full length injection at 90° is recommended.
• Mixing – usually available as premixed form.
• Regular insulin can be mixed with all other preparations.
• Insulin glargine should not be mixed with other insulin.

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