Month: June 2015

Essential Hypertension – it’s just a name


Scientist postulated many years ago that: you need hypertension to maintain cerebral perfusion – especially in the case of atherosclerotic disease. The thinking was that, it was essential to maintain cerebral perfusion… because, if you decrease blood pressure you would damage the brain and the heart because of decreased perfusion due to atherosclerotic disease… therefore, elevated blood pressure was presumed to be “essential” to maintain perfusion…

essential, essential… essential hypertension.

Did you ever wonder why they call it “essential hypertension”? because ~ 40 years ago scientists believed that patients had atherosclerotic disease in your brain and your heart and that hypertension was a normal response to it. Therefore, in order to maintain cerebral and cardiac perfusion – Hypertension was “essential” in obtaining perfusion.

We now know that is false, but the name “essential hypertension” has remained.

Why is it essential? it’s not essential it’s just a name.

examples: why is it called “Rocky mountain spotted fever” when the smallest amount of Rocky mountain spotted fever found in the Rocky mountains?  because, it’s just a name.

Why does a lupus ANTICOAGULANT make me clot? because, it’s just a name.

Why does disseminated Intravascular COAGULATION make me bleed? because, it’s just a name.


Answer to be posted tomorrow

A 78-year old woman was hospitalized 4 days ago after sustaining a left hip fracture due to a fall. She underwent surgical repair with right hip replacement 3 days ago and did not fully awake from general anesthesia until 12 hours after extubation. As her alertness has increased, she has become increasingly agitated. The patients history reveals a 4 year history of Alzheimer dementia. She has no other pertinent personal or family medical history. Current medications include: donepezil, memantine, and low molecular weight heparin.

On physical exam her temperature is 37.2 C, blood pressure is 100/66 mmHg, pulse rate is 100/min and regular and respiration rate is 18/min. The patient can move all four limbs with guarding of the right lower limb. She is inattentive and disoriented to time and place and exhibits combativeness alternating with hypersomnolence. The remainder of the neurologic examination is unremarkable, without evidence of focal findings or meningismus.

Which is the most likely diagnosis?

  1. Acute stroke
  2. Acute worsening of Alzheimer dementia
  3.  Meningitis
  4. Post operative delirium
  5. Pulmonary embolus
  6. Post operative infection

Alzheimer’s disease

Alzheimer’s disease (AD) is a slowly progressive type of dementia that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks.

We believe that the dementia of Alzheimer disease is caused by neurofibrillary tangles, neuritic plaques, amyloid deposition and neuronal atrophy specifically cortical atrophy along with ventricular dilatation.

Interestingly enough, the neurofibrillary tangles and neuritic plaques have a strikingly similarity to the art work of Jackson Pollock

 image 3

Five medications are currently used to treat the cognitive problems of AD: four are acetylcholinesterase inhibitors(tacrine, rivastigmine, galantamine and donepezil) and the other (memantine) is an NMDA receptor antagonist.

Interestingly enough Acetylcholine increases the “output” of your brain.

But, what is the secretion/output of your brain? I believe that the output or secretion of your brain is: thought, beauty, love, goodness, truth… donepezil, rivastigmine, galantamine acetycholine esterase inhibitors are in essence “positive inotropes” for your brain – these medicines are “cerebral digoxins” which increase the ejection fraction of the cerebral output of the brain.

A poet is someone who pours light into a spoon and he brings it and places it on your beautiful holy and parched mouth.

Quick Note: Bupropion

Bupropion treats depression and aids in quitting smoking. Bupropion also prevents depression caused by seasonal affective disorder (SAD).

Bupropion is an antidepressant that produces its primary effects through the inhibition of the re-uptake of Dopamine, Serotonin and Norepinephrine. It is particularly noted for improving the impaired concentration and diminished energy that many patients suffering from depression experience.

Bupropion does not cause the noted sexual dysfunction commonly associated with most antidepressant medications… making it a good choice for younger patients who are trying to have children or concerned about sexual side effects.

An important side effect of bupropion however is a decreased seizure threshold, which is more commonly seen with higher doses. This medication should therefore be avoided in patients with seizure disorders or conditions that predispose to seizures (concurrent alcohol abuse, benzodiazepine use, eating disorders etc…)

Individuals with anorexia nervosa or bulimia nervosa are especially prone to developing electrolyte abnormalities that can precipitate further into seizures. Therefore, a thorough history should be taken along with an appropriate physical exam.