The future of stroke treatment

For too long has the treatment of stroke only consisted in the rehabilitation and prevention. The event in its acute damaging phase was not treatable. After the successful introduction of clot-busting therapies, where thrombus-dissolving agents are administered intravenously, we have now a mechanical option called thrombectomy available, an intra-arterial clot removing approach.

How does thrombectomy work?

Just like a coronary intervention, cerebral thrombectomy uses intra-arterial catheters to access the area where the blockage occurs. And just like a coronary angiography, the procedure is performed by an interventional cardiologist – perhaps in the future renamed to neuro-cardiologist.

The aim is to quickly Identify the area where the obstruction occurs. This is done with an urgent CT-scan on arrival to the emergency department. In order to be eligible for thrombectomy, the blocked vessel in question must fulfil specific criteria relating to its size and location. Only large vessel occlusion and currently just arteries of the anterior cerebral circulation are amenable to thrombectomy. The time frame in which the clot is to be removed is 6 hours, keeping in mind that faster action delivers better results – time is brain.
The catheter is then inserted via the femoral artery and

What are the dangers?

Complications of endovascular procedures can be related to vessel injury caused by the device like perforation, dissection bleeding, vascular access or radiological contrast media.

What is the future holding?

Rapid, safe and effective arterial recanalisation to restore blood flow to minimise brain damage remains the primary goal when managing acute stroke management. Recent positive randomised clinical trials show that endovascular thrombectomy for large vessel ischaemic stroke substantially improved the outcome and reduced disability. To become available for every future stroke patient, this new technology will demand interdisciplinary co-operation, and no doubt require organisational changes within the care provider as well as public awareness and infrastructure.

A clear and simple demonstration of this procedure can be seen at:

Videoanimation

What does your resting heart rate (RHR) tell you?

The resting heart rate gives you a pretty good clue on how ‘fit’ you are. There is a direct link between a high RHR and increased risk of dying from cardiovascular events according to some research.

A study from 2015 found that a higher resting heart rate is associated with a higher risk of dying from a cardiovascular disease, even in people who do not present with the usual risk factors.

It was found that when comparing with a resting heart rate of 45 beats per minute (bpm), the rate for All-cause mortality risk increased linearly as resting heart rate went up. The most significant increase in mortality risk was however at a resting rate of 90 bpm or more.

Further analysis showed a mortality excess of 30-50% for every increase of 20 beats per minute at rest.

What is a reasonable resting heart rate?

A regular heart rate for adults ranges from 60 to 100 bpm at rest.

In general, a slower beating heart at rest is a sign of a more efficient heart function and a fitter cardiovascular condition. A marathon runner, for example, could have a heart rate as low as 40 beats a minute.

If your heart rate is continuously above 100 bpm, consult your doctor. He/she might want to do some tests to find the underlying cause.

How do I measure my resting heart rate?

Do it first thing in the morning, ideally before getting up. Find the pulse on the thumb-side of your wrist, and count how many times it beats within 60 seconds, this gives you the beats per minute figure. You can also check it by counting the pulse in your neck.

Several factors can influence heart rate:

• Activity levels
• Air temperature
• Standing up /Lying down
• Emotions
• Body size/volume
• Medication

How can I improve my resting heart rate?

First of all, start with regular aerobic exercise programs such as cycling, running, walking, swimming or hiking.

It has also been found that a good night sleep can help improve your heart rate. The healthy cardiovascular friendly diet can also contribute to a healthier heartbeat. Try and reduce stress, both physical and emotional and if you suffer from anxiety, try some relaxation therapies. Smoking as well as being overweight also increased your resting heart rate – you know what to do.

Where do cold sores come from?

Although cold sores appear with your cold, they are not caused by the cold virus but an entirely different one, called Herpes Simplex Virus (HSV); to be more precise HSV-1. Many of us carry this virus, sometimes without even knowing and women are slightly more prone to this infection. Over 50 % of the population in the Western World are infected with HSV-1, in some regions of Europe even up to 80%.

Once infected, this virus is likely to stay with you the entire life. It tends to sleep in the nucleus of sensory nerve cells without causing any harm, now and then it may, however, wake up and trigger the typical blisters on the skin from where this nerve conducts sensation. This skin rash typically affects the lips and skin around mouth and nose. It is not entirely known what causes the virus to become active; fever can be a trigger hence the association to the cold and the name “fever blisters”; ultraviolet light is another cause, and both physical and emotional stress may also cause a reactivation. These blisters often start with a tingling and then become painful, they will crust over and heal without leaving a scar. They can last up to 10 days.

How did I get it in the first place?

Infection happens when you get in contact with the virus, and it can enter via breaks in your skin or mucosa. An intact skin does not let the virus though and acts as a perfect barrier. The virus itself can be found in saliva, the affected skin and even tears. Note that it is mostly transmitted from people with an activated HSV, but it can also be given to you by people who do not have any symptoms.
It is recommended that people who are experiencing a cold sore should ensure that their affected skin from touching other people or objects that could act as a mode of transfer and to refrain from exchanging saliva.

What about HSV-2

When we hear Herpes, we associated this word mostly with a sexually transmitted disease. Here HSV-2 comes into play. With the same mode of action like his upper body fellow, this virus affects the skin of the genital areas and is transmitted during sexual intercourse. Traditionally 80% of genital herpes is caused by HSV-2 and 20% by HSV-1. The incidence of HSV-1 infection in the genital area has recently increased. Especially in adolescents, this ratio has moved up to 30-40%, which is explained by increased oro-genital contact.

How to treat sold sores

Cream which contains the antiviral Acyclovir, especially if applied early in the development of cold sores, can help to reduce the duration. In other words, the pain period will be shorter, and the crusting over and healing process will happen faster. Other than that, lip balm against dry lips which often go hand in hand can give some relief.

Antiretroviral Medication as Prophylaxis

Preexposure Prophylaxis (PrEP) with antiretroviral drugs is a concept that is gaining increased recognition as a method of primary prevention for people with a risk of becoming infected with the Human Immunodeficiency Virus. We know what works best in the prevention of HIV but human nature, mainly when guided by their sexual drive, will not always follow the best advice – a fact that even the Catholic church must have realised by now.

Recent clinical trials show promising results for the use of PrEP when delivered as part of a comprehensive set of prevention services for individuals at high risk for HIV acquisition. This approach works best when accompanied by regular monitoring of HIV status, side effects, adherence and risk behaviours.

It is biologically plausible that antiviral medication could affect the acquisition of HIV especially when the prophylactic drug has a long half-life, achieves a high concentration in monocytes, macrophages and genital secretions, has a high barrier to genetic resistance and is safe and inexpensive.

Tenofovir seems to tick all these boxes and is the most widely studied substance either in combination with Emtricitabine (Truvada) or on its own.
The danger of PrEP facilitating resistance and thus spreading a drug-resistant virus is a possibility, especially if this method becomes widespread.
A possibility exists that offering PrEP could encourage increased high-risk sexual activity. However, no evidence of increased high-risk sexual activity was demonstrated in the few observational studies that addressed this.
High-risk individuals include those who have a partner known to be HIV infected or who are sexually active within a high prevalence area. In the gay community, the use of PrEP is becoming a regular feature especially in men participating in anal intercourse.

The future has begun

The FDA has just approved the first chimeric antigen receptor (CAR) T cell therapy offered by Novartis and the second licence for Kite’s CAR-T treatment is expected very shortly. Tisagenlecleucel-T, the product which Novartis calls Kymriah, has received clearance for use in paediatric and young adult patients (age 3 to 25 years) with relapsed or refractory acute lymphoblastic leukaemia (ALL).

Expectations for this new treatment in oncology are high and many patients refilled with hope; some medics go as far as to herald a new dawn in cancer therapy. Should we get excited about CAR-T or is it yet another cancer treatment for the record books of extortionate costs, ending up doing more harm than good?

CAR-T therapy is undoubtedly a novelty in cancer treatment. What makes it promising is that live cells are being used. What makes it unique is that each patients’ own cells are being used. What makes it revolutionary is the that these T cells are genetically engineered to fight cancer. Three high-tech approaches in one Therapy.

“A cell is more powerful to fight disease than any drug will ever be” – from this premise derive all endeavours in immunotherapy which have been driving the Research in T cell receptors since the late 80ies. Encouraging outcomes, however, have only been demonstrated in recent trials, reaching unanimous approval by the FDA. With rekindled interest in T cell therapy, investors are likely to open the money tap to exploit this avenue further.

The concept of T cell therapy

In most cancers, human cells have become malignant through several mutations, which prevent them from self-death (apoptosis) and promote them to uncontrolled multiplication, they have also managed to escape any immune response against them. They can hide from the immune system which does make sense, after all, they derive from tissue that is recognised as own. CD19 is a biochemical feature, or antigens to be precise, that is particular to the blood cancer called ALL. Tisagenlecleucel-T provides a receptor that binds explicitly (hence attacks) on the CD19 molecule.

How exactly is CAR-T therapy produced?

T cells are filtered out from the patient’s blood; a process called apheresis which is available in most clinics. These blood cells are sent to a specialised laboratory to be treated for 15 to 20 days before they return modified and multiplied.

Two major steps happen at the laboratory

First, the T cells are genetically engineered. In other words, a gene, which codes for a particular receptor (the chimeric antigen receptor), is inserted into the T cell’s DNA.

In a second step, these newly armoured T cells are multiplied into many million little fighters.

The finished treatment will undergo several stages of quality testing before it is ready for use

What are the side effects?

Tisagenlecleucel-T binds to all CD19 antigens; this receptor exists not only on cancerous B cells but also on healthy B cells. These play an essential role in fighting infection and producing antibodies against many communicable diseases. Treatment with Tisagenlecleucel-T can, therefore, cause an increase in infectious disease.

Other side effects that have been observed are CRS (cytokine release syndrome) and neurological disorders. CRS is is a type of systemic inflammatory response similar to that found in severe infection characterised by hypotension, pyrexia, and rigours. The patient feels unwell, as if in a state of high fever. It can be treated with the interleukin-6 antagonist tocilizumab. Neurological effects during the trial phase included encephalopathy, seizures, delirium, hallucinations, cognitive disorder, depressed conscious level of consciousness, mental status changes, muscular weakness, and dysarthria – all of them were reversible and could be treated with steroids.

What will the future bring?

By stepping into the commercial sphere, T cell therapy is consolidating its presence in oncology which will undoubtedly lead to further research, trials and investments.

CAR-T therapy might help to improve the tarnished reputation of ‘genetically modifying’.

Today, I am joining in the celebrations of this milestone and believe that CAR-T therapy will play a significant role in the future of cancer treatment. It will need further years of tweaking, but the prospect that one day a T cell receptor can be engineered to detect Antigens of an individual cancer fills me with enormous hope

When again the earth’s northern axis is tilting away from the sun and the days are getting shorter, we know that winter is not far. With the cold season come runny noses, coughs and sneezes and the flu.

What is flu?

Flu is a communicable disease caused by the Influenza virus that spreads via direct contact and airborne droplets. The virus has two main subtypes, A and B. Type A causes more severe symptoms and is responsible for pandemics. B is less virulent, it just lingering around, mainly towards the end of winter.

Unlike a cold, flu symptoms come on quickly including fever and aching muscles. It knocks the toughest out; too unwell to continue any regular activities, you need to rest in bed. Particularly in the frail and elderly, it can cause severe illness or even death.

Flu symptoms include:

• sudden fever
• dry cough
• a sore throat, runny or blocked nose
• headache
• tiredness & weakness
• chills
• aching muscles, limbs or joints
• diarrhoea or abdominal pain
• nausea and vomiting
• difficulty sleeping
• loss of appetite

The flu vaccine

Every year, before the flu season, healthcare providers offer vaccination against this illness, primarily for people who are most at risk. The vaccine consists of protection against a mix of viruses from both subtypes. Scientists at the WHO figure out each year what the likely pathological strains will look like and release a recommendation for a vaccine for the Northern and Southern Hemisphere. Thie vaccine for the flu 2017/2018 in Europe and the US will be the same as the one used in Australia.

The vaccine is undoubtedly the best measure to protect from the flu. Even if it does not match the current virus entirely, it can provide partial protection.

Prediction for 2017/2018

The flu season typically starts in the southern hemisphere, while we are busy sunbathing, it finds the first casualties in Australia and then moves slowly northbound to reach us in November/December. It is more often than not the same strain of the virus.
This year Australia has suffered a severe flu epidemic caused by Influenza A(H3N2), infecting 2.5 times more people than the previous year and with double the fatalities.

In our flu season, we see the same features as the southern hemisphere, which would lead us to expect a higher than average epidemic in Europe and the USA. Unpredictability, however, is typical for viral outbreaks. But if Australia’s large number of flu cases is a reflection on the efficiency of this year’s flu vaccine, our hospitals better brace themselves and get some winter wards ready.
How to prevent the flu?

When you got the flu

If you get the flu and you’re an active, healthy adult you are going to feel too unwell for up to seven days, and you are unable to continue your usual activities; there is usually no need to visit a general practitioner.

Consider visiting your doctor if:

• aged 65 years or over
• during pregnancy
• long-term medical condition
• weakened immune system
• unusual symptoms like chest pain, shortness of breath or start coughing up blood

also if symptoms do not improve after a week or if they are getting worse

Keep up to date with the current flu situation:

• WHO flu surveillance
• USA flu surveillance
• Europe flu surveillance

The health benefits of Potassium

Convenience food is here to stay, so let’s make sure it also caters for the longevity of us consumers. Among many other nutritional disadvantages, our pick ’n nibble diet provides too much sodium (Na+) but not enough potassium (K+). Low potassium intake is associated with many diseases, including hypertension, cardiovascular disease, chronic kidney stone formation and low bone-mineral density.
Comparing our diet with our ancestors’, the Na+ to K+ ratio has inverted and is becoming sodium-dominant. The negative impact of high sodium intake on the blood pressure is a known fact and recommendations to a lower sodium consumption are part of every ‘lifestyle advice’ for prehypertensive patients. In recent studies, the focus of BP modulating electrolytes in our food has shifted to K+.
Potassium from fruits and vegetables has been found to lower blood pressure, especially if not accompanied by a high-sodium intake.

The physiology behind it

Our body has developed many mechanisms to keep electrolytes at a constant level. With regards to potassium this regulation happens mainly within the kidneys; if there is too much dietary intake, it will excrete the excess K+ via the urine.
Renal K+ excretion is regulated by Aldosterone, an adrenal hormone stimulated by high potassium levels in the blood. In exchange of an excreting potassium, Aldosterone leads to an increased absorption of sodium. Our textbooks teach us that a high potassium results in higher Sodium levels. These Aldosterone dominated models of K+ homeostasis are being questioned today. Several studies demonstrate that dietary K+ intake induces renal Na+ loss despite elevated plasma aldosterone. The underlying mechanisms are thought to include enhanced urine flow, reduced renal renin release, and negative Na+ balance. It may need a few more years of research until we discover the exact underlying physiology. In the meantime let’s focus on the evidence.
The relation between high Na+ levels and hypertension, on the other hand, is well established today. A lower Na+ load in our body means less plasma volume expansion and less stress on the heart and blood vessels; in other words a more normal blood pressure.

What does the WHO say

The World Health Organisation (WHO), based on a systematic review of several studies, recommends an increase in dietary potassium to help reduce blood pressure and risk of cardiovascular disease, stroke and coronary heart disease in adults.
The WHO suggests a potassium intake of at least 90 mmol/day (3510 mg/day) for adults, approximately the amount provided by ten bananas.

Yes, you can!

Scanning through foods in the supermarket for ‘yes you can’ rather than ‘ no you can’t’ is much more fun. But for this to happen, the manufacturers need to declare the potassium content on their labels.
I feel that one additional line on our labels is not too much to ask from our food producers, considering the long-term benefits this practice would provide.
Rather than harping on about the sodium vice, we should create the potassium virtue, after all, it follows the evidence.