As we age, we get more health issues. Some will kill, some incapacitate, while others merely cause inconvenience. The incidence of cardiovascular diseases increases as one gets older. Hypertension and irregular heart rhythm predispose to stroke. However, a significant portion of people who suffer a stroke do not have these predisposing conditions. A minor stroke can leave minimal disability but most of the time it will leave the victim with significant disabilities that requires chronic care. In the UK, a recent report from the National Audit Office estimated that the annual cost of caring for people with stroke was about 7 billion pounds. Thus, for healthy individuals, knowing which lifestyle habits are associated with increased stroke risk would certainly be beneficial.

A recent study from the University of East Anglia examined the potential combined impact of 4 health behaviours on stroke incidence in men and women living in the general community in Norfolk, England (BMJ 2009; 338: b349).  The participants were 20,040 men and women aged 40 – 79, drawn from the Norfolk component of the European Prospective Investigation of Cancer (EPIC-Norfolk), with no known stroke or myocardial infarction at baseline survey in 1993 – 1997. They were followed up till 2007. The 4 health behaviours were current non-smoking, moderate alcohol intake (< 14 units per week), physically not inactive (physically inactive means sedentary job and no recreational activity) and a plasma concentration of vitamin C ≥ 50 micromol/L (indicating the consumption of at least 5 servings of fruits and vegetables per day). The study found that the relative risk of developing a stroke is inversely related to the number of health behaviours. Compared to those with 4 health behaviours, the relative risk for stroke for both men and women in those with 3 health behaviours was increased by 15%. The increase was 58% for those with 2 health behaviours, 118% for 1 health behaviour and 131% for those without any health behaviours.

The most well known side effect of smoking is lung cancer. Not smoking at all certainly stops you from having an increased chance of developing lung cancer. Not smoking will also save you money and stop you from smelling like an ashtray when you walk near someone. Now, we know that not smoking would also reduce your risk of developing a stroke. Eating a healthy amount of fruits and vegetables daily coupled with daily exercise are part and parcel of a healthy lifestyle. Instead of taking the elevator to go up a couple of floors, take the stairs instead. You will be surprised how easy it is for you to get enough daily physical activity to put you into the physically active category. Finally, if you like your daily dose of wine, keep to less than 2 glasses per day.

See how easy it is to practice the 4 health behaviours. Don’t think about adopting the 4 health behaviours, just do it! This may just save you from developing a debilitating stroke or, worse still, a fatal one.

A male patient of mine developed visual and auditory hallucinations two days after surgery. This started about 10 o’clock at night. Naturally the family members were quite distressed. This continued overnight and in the morning, the wife was visibly distressed and agitated by her husband’s behaviour. Other family members, with good intentions, kept telling the patient that the visual and auditory hallucinations were untrue.

Acute confusion following surgery can occur for several reasons. Some causes are correctable and some occur without a cause and require supportive measures and the patient recovers spontaneously. Examples of common correctable causes include:

1.      Poor oxygen content in the blood due to poor inspiratory effort, pain which prevents the patient from taking a good breath and chest infection.

2.      Any infection elsewhere in the body.

3.      Blood electrolyte disturbance following surgery or after having been on intravenous infusion.

4.      Cerebrovascular accident.

5.      Alcohol withdrawal syndrome (this can occur when the patient did not admit to being a regular heavy drinker).

It is important for the doctor to exclude the correctable causes and if found, to take the corrective measures to treat the underlying condition. Once these causes have been excluded then the doctor’s role is to institute supportive measures to help the patient through this period. The medication may take a little while to calm the patient.

To the patient, the visual and auditory hallucinations are very real. No amount of persuasion or reasoning from the family members will dissuade the patient from believing in the hallucinations. Indeed, excessive attempts by loved ones to prove to the patient that such hallucinations are false may make the patient more angry and less cooperative.

Post operative confusional state is a known complication following any surgery. It can occur suddenly but not uncommonly tends to come on in the night. It is also more common among the older age group and it affects both male and female patients alike. In the hospital, the patient finds himself in an alien environment with many unfamiliar faces (of health care personnel) coming into contact with him. This is likely to cause disorientation and confusion. In some patients, a slight degree of confusion / disorientation will persist even when it is time for discharge. Once the patient gets home to his familiar surroundings and sees familiar faces of family members, the disorientation and confusion goes and the patient resumes normality.

To the patient, the voices and the visions are real. To the relatives, they are unreal. The natural reaction of a relative is a mixture of fear, frustration and later anger at the irrational insistence of the patient. The best thing a relative can do is be supportive and just be there.

In conventional chemotherapy, when one drug fails to be effective it is quite usual to combine it with another or even two other drugs in order to provide benefit. Now, targeted therapy has joined the ranks of conventional chemotherapy. [Targeted therapy agents are monoclonal antibodies against angiogenesis (growth of new blood vessels). Angiogenesis helps cancer to grow and vascular endothelial growth factor (VEGF) and epidermal growth-factor receptor (EGFR) play important roles in angiogenesis. The antibodies available on the market act against VEGF or EGFR. Bevacizumab (Avastin) acts on VEGF while cetuximab (Erbitux) and panitumumab (Vectibix) act on EGFR.] When more agents of targeted therapy became available, the logic was that by combining these antibodies with conventional chemotherapy, one would expect added benefit when compared to use of one antibody only. The addition of bevacizumab to the FOLFOX / FOLFIRI regime in metastatic colorectal cancer (mCRC) has been shown to be better than FOLFOX / FOLFIRI alone. Thus, adding bevacizumab and cetuximab / panitumumab to FOLFOX / FOLFIRI should, by logic, give added benefit to mCRC patients.

The results of 2 studies doing just that have been published recently. The first study from USA, the PACCE study, involved 823 mCRC patients. In addition to the FOLFOX regimen, the patients also received either bevacizumab alone (the control group) or bevacizumab and panitumumab (the panitumumab group). The study showed that the median free survival was shorter in the panitumumab group (10 months) than the control group (11.4 months). The median survival was also shorter for the panitumumab group (19.4 vs 24.5 months). Furthermore, side effects such as skin toxicity (36% vs 1%), diarrhoea (24% vs 13%), infections (19% vs 10%) and pulmonary embolism (6% vs 4%) were more frequent in the panitumumab group when compared to controls (bevacizumab only group). Another cohort of 230 patients in the same study, treated with the FOLFIRI regime, were also given bevacizumab alone or bevacizumab and panitumumab. Adding panitumumab to bevacizumab did not improve efficacy but led to increased toxic side-effects (J Clin Oncol 2009: 27: 672 – 680). In the second study from The Netherlands, 755 mCRC patients were randomly assigned to capecitabine, oxaliplatin and bevacizumab (CB regimen, 378 patients) or the same regimen plus weekly cetuximab (CBC regimen, 377 patients). After a median follow-up of 23 months, adding cetuximab did not lead to better outcome. The median progression-free survival of the patients on the CBC regimen was shorter (9.4 vs 10.7 months). The median overall survival of the patients on the CBC regimen was also shorter (19.4 vs 20.3 months). Patients on the CBC regimen also experienced more skin toxic side-effects (N Engl J Med 2009; 360: 563 – 572).

Bevacizumab, cetuximab, panitumumab when used alone with other chemotherapy agents have been shown to work. However, when these monoclonal antibody medicines were used in combination, patients did not experience added benefits in terms of progression-free and overall survival. In fact, they experienced more side-effects. This is one case where more is not better.