Mens Health Blog. Medical Blog

Some people may experience minor persistent symptoms that precede and herald their heart attacks. Such symptoms may include a recurring pain in the chest, neck, elbow, or even wrist or back that comes on with exertion or even at rest. The pain may have the quality of a minor toothache or pressure. The clue that something important may be happening is simple: this is usually a new experience, different from any other discomforts that the person has felt before.

Some people feel embarrassed about going to a doctor for fear that he will find nothing wrong. This is wrong in itself. It takes many years of training for a doctor to learn to make a diagnosis accurately, so certainly the average person cannot be expected to be correct in the diagnosis of his own ailments even a fraction of the time. Another group of people tends to minimize all symptoms because they refuse to believe that they could possibly be sick. They have done well for so many years that it is inconceivable to them that they could suffer from a heart attack. Vanity can become a treacherous assassin. The simple truth is that 50 percent of deaths in the United States today are caused by diseases of the heart and blood vessels, and heart attacks claim 55 percent of these deaths. It can happen to you and the chances are that it eventually will.

Many hospitals in the Western world have instituted new programs in an attempt to decrease the death rate from heart attacks. Intensive care units in modern hospitals have increased the patient survival rate. In several large cities in the

United States and England, mobile coronary care units have been established to provide patients with expert attendance during their transport from home to hospital. A recent study has shown, however, that the time required to take a patient from his home to the hospital is but a fraction of the time that is wasted between the onset of the attack and actual arrival at the hospital, where positive measures can be taken to save his life. The patient usually waits hours and sometimes a day or two before he believes that something is seriously wrong and summons help. Since the greatest risk of death occurs during the first few hours of a heart attack, with the probability of death decreasing rapidly after the first day or two, it is obvious that further significant improvement in survival rates depends upon the individual himself.

*4/309/5*

The list of contrasts that can be drawn when the variation in national incidence of cancers is examined across the whole world is endless. We have looked in detail at Europe and in this section we will give a few examples to illustrate that intercontinental differences can be even more dramatic than international differences.

The International Agency for Research on Cancer regularly publishes a compendium of cancer incidence in five continents, the most recent edition of which was in 1987. From these published figures it is possible to pull out some striking examples between the highest incidence and the lowest incidence across the world. The most dramatic is malignant melanoma, for which the lowest known incidence is in Japan (2 cases in every 1,000,000 people every year) and the highest known incidence is in Queensland (309 cases in every x,000,000 people every year); the difference is 150-fold. This is attributable, at least in part, to the combination of light-skinned people exposed to very bright sunshine in Queensland near the equator compared with darker-complexioned people living in the less sunny clinics of Japan. Cancers arising in the back of the nasal cavity are common in Hong Kong (300 in every 1,000,000 people every year) but rare in the UK (3 in every 1,000.000 each year). The explanation for this difference is not so simple but may relate to chronic virus infection with a virus known as the Epstein-Barr virus, and may not exclude other factors such as dietary factors and genetic factors. The Chinese are not always on the wrong side of the equation. For instance, with cancer of the prostate gland in men 900 US blacks out of every 1,000,000 develop the disease each year but 13 in every 1,000,000 Chinese. We find the world’s highest incidence of stomach cancer in Japan (820 per 1,000,000 per year). This is to be compared with a much lower incidence elsewhere, particularly in the Middle East (3-4 per 1,000,000 per year).

The range for the common cancers can also be very large. The highest incidence of lung cancer is 1,100 per 1,000,000 per year in the US but only 58 per 1,000,000 per year in India; similarly colon cancer is 340 per 1,000,000 per year in the US and only 18 per 1,000,000 per year in India; breast cancer is 900 per 1.000,000 women per year in Hawaii but only 14 per 1,000.000 per year in parts of the Middle East. Where we are able to pin down the causes of these variations, the potential for prevention is obvious and large. Where the causes are unknown, the room for research it equally large and potentially equally rewarding.

*23\194\4*

Pathophysiology

In necrotizing fasciitis, fulminant bacterial infection of the subcutaneous tissue results in liquefactive necrosis of the superficial fascia, subcutaneous fat, and deep fascia. Historic and modern terms referring to the infection and its subtypes include hospital gangrene, phagedena, hemolytic streptococcal gangrene, progressive synergistic bacterial gangrene, and many others. Superficial skin initially remains intact as the necrosis extends along fascial planes in as little as a few hours. The exudate is thin and often described as “dishwater pus. Vascular thrombosis leads to necrosis of large areas of skin.

Necrotizing fasciitis can affect any area of the body, but abdominal wall, extremities, and perineum are the most common. The infection begins with the introduction of pathogens into the subcutaneous fascia. Possible routes include trauma, injections, cutaneous infections (including cellulitis, ulcers, abscesses, and varicella), insect bites, deep infections, or hematogenous spread from distant sites. Inciting trauma may be minor and even unnoticed; some cases are idiopathic.

Abdominal wall necrotizing fasciitis is usually a postoperative complication, particularly after fecal contamination of the abdominal cavity. Abdominal wall infections have also occurred after gut perforation, or secondary to other abdominal pathologies. Fournier’s gangrene typically refers to necrotizing fasciitis of the male genitalia and perineum, usually secondary to local infections (genitourinary, intra-abdominal, or perianal), trauma, or instrumentation. Vulvar involvement in women has been described and has similar causes. Head and neck cases are rare but particularly dangerous, given the possibility of spread along cervical fascial planes and involvement of major blood vessels and the mediastinum.

Microbiology

Culture of microorganisms from infection sites reveals two major types of necrotizing fasciitis. Type I is polymicrobial, involving a mix of anaerobic and facultative bacteria, often including Enterobacteriaceae and non-group A streptococci. Type II infections are caused by group A B-hemolytic streptococci (primarily Streptococcus pyogenes) alone or with staphylococci. Increased virulence of some group A streptococcal strains may be related to exotoxins, surface proteins, and variable levels of immunity among hosts.

Abdominal and perineal infections tend to be type I in nature and are typically caused by enteric pathogens. Common bacteria include gram-negative enteric bacilli, enterococci, and anaerobic species, such as Bacteroides and Clostridium species. Most studies have shown that necrotizing fasciitis of the extremities and idiopathic cases tend to be type II in etiology. However, many observational studies may not have used rigorous anaerobic bacteria isolation methods, and one large case series described mostly polymicrobial infections predominated by anaerobes in any site.

Marine Vibrio species, most notably Vibrio vulnificus, may cause necrotizing fasciitis following contact with seawater, fish, or shellfish. Other causes include group В streptococci, Pasturella multocida, and Candida species.

*120/348/5*